New emergency medicine level of service billing changes coming in 2023! @EmergencyDocs @ACEPNow @JeffreyLDavis44 just released a really helpful FAQ, thread calling out the big points: 🧵

FAQ here https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs/

In case you missed the prior thread with an overview of the changes, thanks again to @RobPNorris. Now on with the FAQ:

https://twitter.com/grahamwalker/status/1573430425069887489

No, you don't have to include all the long ROS, PE, Social Hx, etc. BUT your H&P should include pertinent info to tell the story/support your MDM (and don't forget medico-legal stuff).
Ex: If you're gonna "count" MDM points for "independent historian" you better mention who&why

An ER-focused table/grid is available here as a PDF: https://www.dropbox.com/s/pg1xt9hnk97zjnz/ACEP%20-%202023%20ED%20MDM%20Grid.pdf?dl=0

As a reminder your "two highest MDM categories" yields the final CPT code 99282-99285 (bye 99281! 👋)

The PDF lays out the columns much better, gives examples pertinent to EM. Bravo. 👏

Number & Complexity of Problems Addressed (COPA): Very nice list of examples of what "minor&major" and "stable & complicated" can mean.
It's a little overwhelming but I think we'll get used to it with time. Roughly:
Admitting = High
Working up = High/mod
Rapid Care = low/mod

Amount and/or Complexity of Data just kind of sucks. It's awkward, you have to count points of sub-categories, etc. It's really worth reading the FAQ but I'll go into the important subtleties

VERY IMPORTANT:
ALL CATEGORY 1 POINTS CAN JUST COME FROM ORDERING TESTS, which is probably going to be the easiest way to document satisfying these criteria (since if you're working up a patient, they're getting several tests like CBC, Chem7, UA, etc)

Interpreting labs — "high BUN/Cr ratio, anemia, will do rectal exam for syncope" does NOT count for "independent interpretation," only things like you giving your read of an EKG, XR, rhythm strip, etc.

For category 1, "external notes" is literally anything outside of the ED — could be a clinic note, inpatient chart, nursing home note, even an EMS report.

The only time you're not gonna get a point for this is if the patient walked in and they're literally a blank slate.

So I think generally patients getting any workup more than Rapid Care — will be "moderate." Maybe "dysuria" you're ordering a test but treating empirically, so they would be "limited," but even most ankle sprains will get 1) XR 2) XR interp by you 3) review of their prior records

Independent historian (Category 2) is literally anyone that's not the patient, (including parents of children), MINUS interpreters of course

Discussion of management (Cat 3) is any consult — could even be staff of a nursing home, home health, etc (ie: not necessarily a doctor)

BUT you must do the discussion, not a nurse or case worker

The last column - amount of risk or morbidity/complications is probably super intuitive since most of our job is risk stratification.

Will this take a bit of time to get used to, especially the "Amount/Complexity of Data" rules? Yeah. But I think probably within 6 weeks we'll all have a general sense of where patients fall based on their chief complaint, co-morbidities, workup needed, etc.

General rule is if you're gonna "count" something toward MDM, it needs to be documented. (Something you probably already do more or less.)
But I think if you're giving IV morphine, that's already in the MAR and you probably don't need to call it out in your note?


I think overall it's a major major improvement, and over time will hopefully reduce note bloat, clicks, and garbage in clinician notes. Like everything in medicine, it was only about a decade overdue for change. Thanks again for the FAQ via ACEP and the Documentation/Coding team!

You can read the unrolled version of this thread here: https://typefully.com/grahamwalker/nDYXCqx

Medical Decision Making FAQ Review for EM Coding

Came across a health design contest I entered in 2012 and couldn't believe the site was still up! 💡Ideas I still think are good: This is the Health Matrix, patient clicks on diseases or drugs or doctors and it shows them how they're all related and their importance (square size)

Many patients don't know their meds, so this med list includes photos of the pills, why they take them, which body system, and the sig:

Schedule view! When to take what, and how much to take!

Most recently prescribed, including short-term meds like antibiotics and when they should finish the course. Also highlights changes in doses/sig.

List of health problems, including 1️⃣ "what I can do about this" and 2️⃣ "what causes this"

A written summary in plain English of the patient's most recent lab results, including alerts for things that are abnormal and can be dangerous.

Note the labs are grouped by "Bleeding" or "Electrolytes" or "Kidney and Liver" not by the damn lab test we ordered, like a Chem7 or CBC!

Also: visual, relative lab values (with the option to hover to see the actual values)!

And, of course, a "doctor view" which goes into more detail, has diagnoses in "medical-ese," and trends labs. (This is the one thing I'm okay with now — table-view of labs, and no more of these cryptic fishbone diagrams.)

Did anyone else submit a design? This was a design challenge to redesign the CCD (Continuity of Care Document). Would love to see what others are doing now! (Sadly, I don't think any of these designs actually made it into a CCD). @devpost @ONC_HealthIT
https://healthdesign.devpost.com/

My site is still up somehow! https://healthee.site44.com/ @nickgenes @cddirks @Health_IT @mshlcurrie  @RAdamsDudleyMD @emlitofnote @dirkstanley @MattSakumoto @RobPNorris

You can read the unrolled version of this thread here: https://typefully.com/grahamwalker/4G74YYg

My CCD Health Design Submission from 2012

Quick thread on changes to emergency medicine billing requirements coming in a few months (Jan 1, 2023)!

Most importantly: goodbye to the absolutely inane HPI, ROS, and PE elements for billing. Hooray! Instead, EVERYTHING is based on medical decision-making (MDM). ⬇️⬇️

Props to my friend and colleague @RobPNorris who spent a ton of time summarizing all of this. I'm stealing his slides. This is all based on AMA guidelines here https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

Unfortunately MDM is a Russian doll of onion layers of complexity that only CPT and the AMA could have mustered. But the top level elements are:
1️⃣Number/complexity of problems addressed
2️⃣Number/complexity of data assessed
3️⃣Risk of complications/morbidity

Essentially you're gonna get "points" or "levels" for those 3 elements, and your two HIGHEST levels will determine your overall MDM complexity which will then be a billing code
99282 = Straightforward
99283 = Low
99284 = Moderate
99285 = High

I know. It's obnoxious. Each Problems/Data/Risk section gets assigned its own "straightforward/low/moderate/high" and has its own definitions for these scores. It's annoying.

But still, it ain't 10 review of systems.

I'll go through and just list these out, and then give what I... think? ... would be examples? @RobPNorris took these directly from the AMA PDF.

Number of problems/complexity of problems:

Amount of Data/Complexity of Data

This is where the Russian Doll starts to get pretty ugly; you'll notice "Must meet X of 3 categories" to determine "Level of Data Complexity" (this one could benefit from simplification)

Level of Risk/Morbidity I think is relatively straightforward; they give examples but I think emergency physicians should be able to categorize this risk very easily.

Important points:
Shared decision making is specifically included! If you would normally/often do X for a patient but the patient opts out, X still counts toward testing/risk/complexity. (X could be "admit to the hospital" or "get a CT scan" or "order a troponin.")

LOS 1/99281 is pretty much no longer a thing for emergency medicine. I don't even really understand what an ER visit that "does not require a physician or other healthcare professional" means.x


Critical Care is still a separate billing code; procedures as well are separate.

So what do I think this will look like for the future of EM documentation?
—Focused HPI like you're probably already doing
—*Relevant* ROS, Social, Family History, PMH in the HPI
—Focused, *relevant* physical exam documentation
—(A little) more time on MDM, probably not much

As @gerardo_gb says — I'd really love EM to lead all of medicine in moving to APSO (Assessment/Plan at the 🔝 of the note, Subjective/Objective below it). It is MUCH easier for people reading your note to skim and see the important, relevant parts with APSO.

https://twitter.com/gerardo_gb/status/1573413901924024337?s=20&t=oTm5Q0fRAG40D0ezzE75HQ

What might this look like in practice? I mean could this "rule out appy" note be a pipe dream? Could my ER note 👇really be this straightforward, containing almost exclusively-relevant information to the patient's CC? And fit in 20 lines?

Of course it's not gonna always be this straightforward. But for the straightforward cases, could I really document this little and still demonstrate the medical complexity, risk, and problems along with any med-legal stuff? I think this would be a 99285 chart. Let's look:

Now what I honestly don't know, as I'm not a documentation or coding expert, just a Very Basic ER Doctor:
➡️Do I have to document "Risk/Morbidity is high With Appendicitis" in order for it to count? I sure hope not, that seems repetitive and stupid.

➡️Same with adding some line about "I reviewed the patient's prior notes" in order for it to "count."

Still many questions. I'd love anyone who's actually an expert here to chime in here!

Let me try again, with another straightforward example: simple lac repair:

I think arguably this is either a Straightforward (99282) or a Low (99283) depending on interpretation and such, PLUS a simple lac repair procedure code.

Overall I think this is going to be a major net WIN for emergency medicine. It will absolutely take some time for the specialty to get used to the MDM criteria, AND for us to de-clutter our notes, but even doing those two fake patient notes — it was much simpler/faster.

cc to people who commented
@ScholerinED @MDaware @Lgaard @gbosslet @mattjbrunner @reverendofdoubt and also @EdGainesIII who I feel like always knows about money stuff with emergency medicine

You can read the unrolled version of this thread here: https://typefully.com/grahamwalker/vxBOyDP

2023 Emergency Medicine Coding/Billing Updates

Isn't it kind of incredible that you can prevent your older self from getting cancer? Here's my own recent adventure in fucking future cancer in the ass (literally), and why you should say "Fuck Future Cancer" too:

I'm 42. I recently developed some weird 💩-related symptoms that definitely had my doctor-brain worried that I might have an early colorectal cancer (more on that later). I talked to a few colleagues, and off I went early Wednesday to have a flexible sigmoidoscopy.*

A "flex sig" is a small, VERY-lubricated camera that goes up your butt and can look for bleeding, cancers, hemorrhoids, or anything else in the last parts of your colon, called the sigmoid & rectum. It's about the diameter of your pinky.

You have taken much bigger dumps.💩

Since normally there's poop in those parts of your colon: yes, you have do a clean out so the GI doctor can see things clearly. It's about 2 medium Gatorade bottles-worth of liquid, some stool softeners, and some Gas-X. And then a bunch of stomach rumbling and pooping.

It's not painful at all. There's no cramping or burning. It's just frequent and annoying, because normally your rectum—amazing organ than it is—just lets you sleep and holds onto your poop for you until morning. So I was up every hour or so. Annoying. 🤷‍♂️

The flex sig is a 5-10 minute procedure for many patients, and I chose to do it without any sedation, because I had shit to do later that day. (Pun intended.) There was maybe 30 seconds or so of pressure, like I needed to poop? But really not that bad.

And since I'm a doctor and honestly the human body is just really incredible and amazing, I watched the screen and marveled at my large intestine while my doctor painlessly removed a small polyp and found a few hemorrhoids. Nothing more, phew.

The reason I bring up this overly personal story? I know 3 men in their 30s with colorectal cancer, and one of them is dead, and left behind a 6 month-old baby. 

Colorectal cancer rates are rising in young people AND being diagnosed LATE.

You may have heard that the GI and cancer specialists recently lowered the screening age to 45, and it's because of more cancers in younger people now. Rates AND deaths are going down in people over 50, and going UP in younger people:

AND younger people are presenting with more advanced cancer (probably bc they're not being screened AND they/their doctor don't necessary know the symptoms). Look at this: 90% of people under 50 had symptoms at diagnosis, and had symptoms for 8 MONTHS before diagnosis!

So what are the symptoms? Often for young people they're not very specific — which is why they can be missed: 
—Change in bowel habits (new long-lasting constipation, sometimes diarrhea)
—Fatigue (often due to anemia)
—Rectal bleeding
—Cramping/abdominal pain

Later symptoms can be things like unexplained weight loss, or a change in the size of your poop.

NB about the first one: UNEXPLAINED WEIGHT LOSS (more than 5-10 pounds) IS NEVER NORMAL, IS OFTEN CANCER, AND YOU NEED TO SEE A DOCTOR. PLEASE *PLEASE* TAKE THIS SERIOUSLY.

Now, we don't exactly know why younger people are getting cancers. It's probably some combination of low-fiber diet, sedentary lifestyle, obesity, and increased alcohol intake. 

But there's really great news:
Often colorectal cancers can be PREVENTED and/or caught early with screening! 
Almost all colorectal cancers start as colon polyps, and if a GI doctor removes the polyp, they prevent it from turning into cancer (which often takes 5-10 years).

There are lots of different screening tests with various pros and cons. This is a nice graphic of 3 common types of tests, colonoscopy (a procedure) and two types of non-invasive tests where you actually send in your poop and check it for blood, since cancers tend to bleed.

Remember, screening begins at age 45, and the type of screening really depends on your medical history and your preferences. Your doctor can help you decide. (People with certain family history or other diseases probably need a colonoscopy, and may need it younger than 45.)

(The other thing to consider is that if you have a positive non-invasive poop test, like FIT or @Cologuard which must be done yearly, then you need to have a colonoscopy anyway, which is why many people opt to just get a colonoscopy every 10 years in the first place.) 

And just a point of clarification: if you have symptoms regardless of your age, a) you need to see your doctor and 
b) you're no longer being "screened" for cancer.
Screening is something we do for people *WITHOUT* symptoms of a disease.

Well if you're made it this far into this boring thread, you deserve an award. And that award is: a photo of my polyp! Ain't it precious? cc the OG @katiecouric 

*Just to be clear, I had a flexible sigmoidoscopy after discussion with my doctors and my very specific symptoms—and if my polyp was a pre-cancerous one, I would have needed to get a colonoscopy. Luckily I think I'm all good.

Thanks for reading; get screened and get your partner or parents screened if they've been avoiding their colonoscopy—and any GI doctors with corrections or comments, please comment below!

Finally, for all the sufferers and survivors: FUCK. CANCER.

Thanks to my wonderful doctors who didn't make me feel embarrassed for talking about butt issues with them and research and images from my friend @mohammad and @AmerGastroAssn @AmericanCancer @CDC_Cancer @theNCI 

You can read the unrolled version of this thread here: https://typefully.com/grahamwalker/zMS7n5z

PS: I wrote this thread with @typefully. https://typefully.com

You Can Literally Prevent Future Fucking Cancer

Proud to announce WTFentanyl.com, a resource to correct the ridiculous misinformation about fentanyl exposures online that spreads at a fever pitch these days. Please take a look and bookmark for future reference. You can also reference @WTFentanylBot in replies!

(Formerly the bot was @FentanylSafety but that URL was associated with... more fentanyl misinformation, so we're using @ryanmarino's #WTFentanyl inspiration instead.)

You'll find basic facts about fentanyl, evidence proving that touching fentanyl does not harm you (in the form of 📝journal articles, 👩‍🏫position statements, 📰news articles, and 📹videos) as well as FAQs and info about how this whole mess got started.

The site is supported by an incredibly amazing team of physicians and pharmacists that I couldn't be prouder to work with: @RyanMarino @jtrebach @toxicologist12 @Runde_MC @EMPoisonPharmD with special thanks to @khudhur_moh, a junior doctor in Iraq who helped create the graphics!

See fentanyl misinformation on Twitter? Reply to the person with @WTFentanylBot and the bot will take care of the rest, sending them WTFentanyl.com and explaining the site to them.

Additional thanks @vercel for hosting the app and blowing me away with an incredibly simple serving system and for @Rich_Harris for getting me excited about web development again with @sveltejs. (This is just a basic info site without interactivity but still totally fun to make!)

cc @MorganGodvin - Great piece on fentanyl test strips https://filtermag.org/fentanyl-test-strips-counterfeit-pills/
@ZachWritesStuff - What’s Really Going on in Those Police Fentanyl Exposure Videos? https://www.nytimes.com/2022/07/13/magazine/police-fentanyl-exposure-videos.html 

@ellefs0n - Are Police Overdosing By Touching Fentanyl? Experts Say It’s Unlikely. (buzzfeednews.com) https://www.buzzfeednews.com/article/lindseyellefson/fentanyl-accidental-exposure-police
@ReutersFacts - Fact Check-Overdose of fentanyl just by being in its presence is not possible, experts tell Reuters https://www.reuters.com/article/factcheck-fentanyl-overdose/fact-check-overdose-of-fentanyl-just-by-being-in-its-presence-is-not-possible-experts-tell-reuters-idUSL1N2PI0PZ

Announcing WTFentanyl.com - Correcting Fentanyl Misinformation

Are you a former Gifted Kid? Anxious about trying new things as an adult because you'll be bad at them? Me too! I'd highly recommend a video from psychiatrist @dr_alokkanojia on his channel @HealthyGamerGG. Video inside 👇

https://twitter.com/kindofsquishy/status/1306355884650455040?s=20&t=ZoUwNyegPaOD2nLYnGJzVQ

The full video is long, but I think Dr. K does a great job of explaining the psychology of "growing up gifted." It's of course only a theory, but rings true for me. Here's a clip, and I'll summarize some of his message below.

1️⃣Gifted Kids get by academically through childhood and adolescence using their intellect, but at some point start to rely on their intellect/IQ for almost ALL things, instead of developing other parts of themselves, like EQ, social dynamics, other life skills, etc.

2️⃣Gifted Kids often define themselves by their gifted-ness. It's our Identity. By definition, gifted means "effortless success." So we steer ourselves toward things that come naturally to us, and avoid things that are hard for us.

3️⃣Gifted Kids have a hard time getting help, because our cognitive biases are so strong — our brains are great at coming up with evidence about why we're always right about something! Dr. K calls this "Help Seeking / Help Rejecting." 

They may know they want or need help in a certain area of life, but their intellect is so good at thinking through all the possibilities (and their likelihood) that they may jump to a conclusion — and by doing that, make a self-fulfilling prophecy.

I hate to keep inserting all these clips — because the entire video is just *so* good — but Dr. K highlights this self-fulfilling prophecy so well by describing not wanting to go a party because you're not sure if you'll have a good time:

(Have I convinced you to watch the whole thing now?)
As a former Gifted Kid turned "anxious adult with thousands of abandoned hobbies" — I think this video will really resonate with you, or help you with your own Gifted Kid in your life.
https://www.youtube.com/watch?v=sQC0jfH_rrM

I cannot thank Dr. K enough for his videos (posted freely to his Youtube Channel) https://www.youtube.com/c/HealthyGamerGG and his Twitch channel. I have no affiliation to him, but he has a foundation you can support, and also signup for coaching from his team too.
https://www.healthygamerfoundation.org/

Twitch is a streaming website where gamers can watch their favorite players and chat with them. Dr. K uses the streaming platform to discuss mental health/life questions sent to him and interact with viewers (who often have the same issues).
https://www.twitch.tv/healthygamer_gg

We desperately need new models for mental health, this is one: Internet-based group therapy, providing a really healthy space for many to discuss their problems, understand them, talk about solutions, and see that the problems are shared by others (yet still be fairly anonymous).

The channel has videos on tons of other topics:
Wasting Time on the Internet: https://www.youtube.com/watch?v=RPzV8fWmKPY
What Is Meditation: https://www.youtube.com/watch?v=dvq48pfJa9w
How ADHD Makes Life Hard: https://www.youtube.com/watch?v=svD71EJWOBU
And live interviews with people about their mental health:
https://www.youtube.com/watch?v=LVxKF5SuVC4

This is not "Woe is the poor, suffering Gifted Kid." It's just a great example of everything in life having upsides and downsides. And a sense that we all have struggles, and can all improve.

(Thanks to Dr. K for allowing me to clip and include these videos, and I also have to plug @clipchamp which I recently discovered as a great free tool to clip videos in the browser and @4kvideodownload to easily download Youtube videos as well.)

You can read the unrolled version of this thread here: https://typefully.com/grahamwalker/6yPEucW

How and Why Gifted Kids Struggle

Today is day 85 since the first confirmed US monkeypox case. If you graph out cases relative to the gay male population, it starts to look a lot like the 84 days of early 2020: infecting ~0.2% of the population. COVID-level growth in gay men.

And I say this obviously not to stigmatize, nor to blame, nor to scare.
I say this because I agree with @benryanwriter in his powerful Op-Ed today: gay men need to protect and care for ourselves because our institutions aren't doing that.
https://twitter.com/benryanwriter/status/1557712101518589953

This is COVID-level growth in our communities. Remember what happened when COVID hit? Do you see anyone or anything taking this ANYWHERE near as seriously as the infections in the gay male community? I don't.

We need vaccine, yes. But we also need *vaccine data.* We do not know very clearly how effective this vaccine is. Getting your Jynneos today does not mean you're in the clear next week. Gay men are still getting MPOX early after vaccination. We don't know how protective it is.

So we have to talk about changing (or pausing) behaviors. Sexual practices. Hookups. @fakedansavage started to talk about this in May. Many others have. But many others haven't.

I guess it's better to let your community get a disease than be direct and honest with them?

Gay men tend to really care about their bodies and their health—partially because we learned from HIV/AIDS that the federal government wasn't going to. And we need to do the same with monkeypox: care for ourselves, our community, and stop this painful, awful disease.

*Yes we need more testing, yes I realize there are non-gay-men getting MPX
*Yes I realize some people are getting it without sex
*AND ALSO STILL gay men are the most impacted, and most cases are probably from contact during sex

**I'm estimating ~5.9M gay men based on the US population and the most recent US census data survey, acknowledging these #'s are rough, that not all gay men are high risk and not only people who identify as "gay men" are high risk for MPX.
 https://www2.census.gov/about/training-workshops/2021/2021-06-24-data-summit-presentation.pdf

85 Days into MPX: COVID-Level Growth in Gay Men

You can read the unrolled version of this thread here: https://typefully.com/grahamwalker/wvx03wC

85 Days into Monkeypox: COVID-Level Growth for Gay Men

Change My Mind:
I do not support waiting for a blinded randomized placebo-controlled monkeypox trial before expanding access to tecovirimat(TPOXX).
Despite being an online educator and supporter of evidence-based medicine. Is my thinking wrong? 💬

My main reason is that I think TPOXX can help stop the spread of MPX in this country. If it shortens the duration of illness, and illness duration is similar to contagiousness duration, that alone is worth it. See this Op-Ed @LeoNissolaMD @theIDPharmD 
https://www.stateofthevirus.com/blog/fda-should-expand-access-of-tecovirimat-for-monkeypox-now

(And lest I be called out: it's also because TPOXX appears to be very safe and well-tolerated.) Main side effect in the TPOXX trial? Nausea, which is an extremely common side effect of many drugs, and usually easy to manage. Here's the list:

And of course we don't know about long-term risks or side effects, or effects in the larger population. But we don't know that of *any* drug after an randomized trial —which is why the FDA has Phase 4 of Drug Monitoring: once approved, drug side effects are still reported. 

I should also add that the anecdotal data on TPOXX is also compelling. (Yes I'm aware that the plural of anecdote is not data). 
Look at these recovery photos starting pre, day4, day7 TPOXX:

Yes, randomized controlled trials (RCT) are the best evidence that Drug A caused outcome X. And for COVID interventions—vaccines, paxlovid, steroids, etc—I demanded them. (I commonly speak out that Paxlovid has not been shown to help vaccinated people, for example.)

But we have other types of studies and evidence. They're not as strong of evidence, but: they exist because for one reason or another, conditions in our world don't make an RCT appropriate. 

And for me, this is the clincher: we are in another pandemic. But THIS TIME, we ALREADY have something that could stop it from spreading more widely, say to children. Or to colleges. Or to jails.

Look at that 🇺🇸 line I highlighted: WE ARE RAPIDLY CATCHING UP IN PER-CAPITA CASES.

Finally, I'll admit my bias: this is personal and emotional. I'm a gay ER doctor in SF.
—This is pandemic #2
—I've treated MPX patients my same age
—I have seen genital lesions so upsetting and intrusive that I have had counseling on how to erase them from my mind.

So please, tell me if my thinking is wrong. Sure, ideally we'd do an RCT. But is it really worth waiting 6-9 months for a trial to get published when TODAY we have less than 10,000 monkeypox cases in this country? Because 11 days ago, we only had 5,000.
I'll let you do the math.

And you know what? We already have PLENTY of placebo controls for any trial that needs them. They're called "gay men with monkeypox who we wouldn't treat."

We need expanded TPOXX access now. We need an emergency use authorization.

Adding a bunch of evidence-based medicine experts who I respect @TheSGEM @tamingthesru @Runde_MC @First10EM @EMNerd_ @PulmCrit @nickmmark @EMSwami @emlitofnote @GidMK @srrezaie @spoonfedEM @thenntgroup @SZehtabchi 

I also want to highlight this article from the LA Times that helped me cement my thinking in this (I literally just wrote this thread this morning, had no idea the article would come out today.) 

https://twitter.com/AlpertReyes/status/1557371309985738752?s=20&t=HYu2_-00YUmFh5pxmPgyBg

And a big TY to the patients on Reddit's monkeypoxpositive forum for sharing their stories and photos https://www.reddit.com/r/monkeypoxpositive/comments/wb9fjf/my_tpoxx_journey_great_progress_just_finished_day/


Change My Mind: We Don't Need an RCT for TPOXX

I’m sick and tired of gay men being misdiagnosed with something ELSE when it’s clearly monkeypox and you can’t be bothered to examine them or take a history, doctors.
THIS IS NOT ROCKET SCIENCE
Take two✌️ minutes and let me catch you the fuck up.

Seeing a patient with a new rash, especially if it:
—is around their genitals 🍆or anus🍑? 
—has another new distant lesion (face, arms)
—looks like papules, vesicles, pustules, or ulcers
—is in a gay man, esp with new partners?

Yeah. It's probably monkeypox.

So you put on your big boy PPE (I double glove because I'm often touching my phone for photos or swabbing lesions) and talk to the patient. You ask them these straightforward questions (this is called "taking a history.")

No one is going to care that you're in PPE. It's FINE.

These patients are scared and in severe pain. Many are healthy and young and have literally never had a medical problem before. All they want is your help. They would not wish monkeypox on their worst enemy. They do not want you to get monkeypox from helping them.

You ask them some additional questions:
—Anyone you're aware of have monkeypox recently?
—Do you know your HIV status? 
—Can I test you for other STDs today? (30% of MPX patients have had other concurrent STDs)
—Have you had a fever, headache, or swollen lymph nodes recently?

🌈Gay men are legit the simplest patients to take a history from. Seriously. When did the headache start? They can tell you what they were doing when it started. How high was the fever? It's on their camera because they texted the thermometer picture to their friend. Easy mode.

Fever/lymph node swelling is common but not present in everybody, but often the lymph nodes are a dead giveaway for monkeypox (but keep your differential open!)

Rectal pain is another common presentation of monkeypox. Ask about it.

Now you *examine the patient*. This is where you will look and touch their body. Most people will know where they have noticed lesions, because they have probably looked themselves up and down already many times, and have taken photos on their phone.

Ask about lesions in the mouth, people usually know if they have any. Ask about other rashes too, since MPX can present with a generic maculopapular rash along with pox.
https://twitter.com/grahamwalker/status/1552817990906744832?s=20&t=gLf9nsAyNlwkZNZ_zeDd4w

Also: 10% of people will have only ONE SINGLE LESION. None of this "monkeypox is ruled out, there would be more lesions" nonsense. 

I can't.

Okay, now look at their genitals/lesions in sensitive areas. Patients have no problem moving their junk around so you can get a good view, swab, get photos.

Early in the dz I think there are many more false negative swabs: if the lesions aren't open, you're probably not getting nearly as much of a sample. I have started asking patients what their lesions looked like and when they were swabbed — if they weren't open, maybe false neg.

I've had 1 pt that had what looked like "folliculitis that wasn't going away" on his face and 1 lesion on his groin, but had all the other symptoms — fever and lymph nodes, severe rectal pain. I did anoscopy with LOTS OF VISCOUS LIDO and saw multiple lesions. Voila, monkeypox.

Could it be herpes or something? I mean, I guess. You can send an HSV swab if you want, no one will fault you. And sure, there are gonna be some herpes outbreaks as well. But especially if they have other symptoms, or many lesions? Yeah, it's probably not herpes then.

I'm offering multi-modal pain meds to these patients: motrin, tylenol, opiates, topical lidocaine, and a trial of gabapentin and mesalamine suppositories (the last two I've heard some colleagues having success with and I think are very low risk to try). Sitz baths might help too.

Don't forget to test for other STDs—or have them do it themselves. Swab their throat and butt for GC/C, test for syphilis and HIV. Or refer them somewhere that can.

And if they're not on HIV PREP and having unprotected sex, sounds like PREP might be right for them.

These patients need to isolate, and if they're in the "yeah this definitely seems like monkeypox" category and it's early in their disease, they can get post-exposure vaccine. Talk with your county health dept or your ID or HIV doc to get them connected.

I have never met patients more grateful to be seen. Despite hours w long waits.
Honestly. These patients are so scared, in so much pain, and so desperate for someone—anyone—to talk to them and examine them and help them. 
You can be that someone, wear your PPE, and be at no risk.

Sorry for the cursing eaerlier but this is the 2nd pandemic that I've been volunteered to be the front line for, while seemingly most of medicine can't even be bothered to take a proper history from the comfort of their telephone or video visit for these patients. 

I'm tired.

These patients think I’m some kind of miracle worker for just talking to them and examining them.

The federal government has let them down. They can't get vaccinated. They can't get treated. They can't even be seen.

And when we fail them too? A pox on the house of medicine.