People commonly refer to upper respiratory infections as the “flu”. This is used as a catch-all term, however true “flu” is caused by specific influenza viruses that affect the respiratory tract, usually with more severe symptoms, and can rarely cause death (0.1% mortality rate during each average severity seasonal epidemic). Worldwide pandemics occur occasionally, the most devastating occurring in 1918 when 40 to 100 million people died. Mortality rates during these pandemics can be much higher than the usual 0.1%.

Influenza viruses that can cause severe epidemic illness are the A & B types. While humans can develop immunity to these viruses either through infection or immunization, these viruses genetically alter their RNA from year to year, so that immunity is temporary. This is why influenza re-vaccination is recommended by the CDC on a yearly basis.

Influenza season typically occurs from November to April in North America. Peak season is from January to March. In our medical house call practice here in San Francisco, we see many travelers from the southern hemisphere including throughout South America. It is not unusual for us to diagnose influenza in the summer months in these patients, since they have come from their winter season back home.

Influenza Illness

high fever (fever not always present)
cough
sore throat
runny nose or nasal congestion
headache
muscle aches
profound fatigue or weakness

Nausea, vomiting, diarrhea can occur with influenza, but are not typical symptoms of influenza. “Stomach flu” is a catch-all term used to describe illnesses that include these symptoms, but does not specifically refer to influenza.

Influenza illness usually lasts a few days to 1 or 2 weeks. Occasionally complications such as pneumonia may develop, which can lead to more serious illness or even death. Those at more risk for complications include the elderly, very young, and people with other chronic illnesses. During the recent H1N1(type A) influenza outbreak, a significant number of deaths occurred in otherwise healthy young persons.

Prevention

1) Frequent hand washing, and avoidance of touching hand to mouth, eyes and nose. Use antiseptic hand wash such as alcohol based wipes.
2) Influenza easily spreads via respiratory droplets from patients who are coughing, so avoidance of close proximity to people who are coughing is prudent. Cover mouth and nose when sneezing or coughing when sick.
3) Consider yearly influenza vaccination. For specific recommendations see CDC guidelines

Treatment

Bedrest
Minimize contact with others
Rehydrate
Use over-the counter medications as directed for symptom relief
See your doctor within 48 hours of the onset of symptoms if possible, since antiviral medication may be of benefit if started within the first two days.
Antibacterial treatment may be recommended for certain cases, since bacterial pneumonia is a common complication of influenza.

House calls & Influenza

For patients with influenza symptoms, a physician house call is always a welcome service. Patient’s with influenza should ideally remain at rest, and should not expose other patients to this highly contagious illness. Patients with shortness of breath or severe symptoms should call 9-1-1 or go to their nearest hospital emergency department immediately.

The Housecall Advantage

Highly convenient
No travel required
No public waiting rooms
No trip to the pharmacy required
No exposure to other sick patients
Minimize exposure to hospital “superbugs”
Housecall doctors tend to be unhurried
Easy 24 hour telephone access for followup questions and advice

The Housecall Request

When a patient inquires about our service for wound repair or care, the physician will ask questions to learn the nature and severity of the wound, and whether tetanus vaccination is needed. Once the doctor determines that a housecall would be appropriate, and if the patient then agrees to the service, a physician will respond with a given estimated arrival time. The patient remains in the comfort of their own home or hotel room.

The Housecall

Upon arrival, the care provider will examine the patient, then offer treatment options, which may include suturing (stitches), adhesive or staple placement. Tetanus prophylaxis may be given if appropriate. A sterile field will be setup, usually involving sterile drapes placed around the injured area. Our patient’s comfort is top priority and we will always take the time to ensure adequate anesthetic pain relief prior to performing any procedures. The wound will then be cleansed, repaired and bandaged. Occasionally antibiotics or other medication may be dispensed or prescribed. Paperwork, including a form for insurance reimbursement will be completed. Detailed instructions will be given to the patient regarding followup care.

Followup Care

Patients may call us anytime 24/7 should they have questions or if problems arise. Sutures or staples may be removed by our doctor or any qualified medical provider. For certain injuries, specialty surgical followup may be arranged by us or by your primary doctor.

Why a Housecall?

Vomiting and diarrhea, usually due to stomach flu or food poisoning, are a major reason that patients call us. While these symptoms often resolve within hours, occasionally they are severe and persistent, causing significant dehydration. Patients with nausea, vomiting, diarrhea and dehydration do not want to travel to their doctor or sit in public waiting rooms. Remaining at home, in bed, with quick and easy access to the bathroom is the most comfortable option.

The Request for a Housecall and the Response

When we are called to evaluate and treat patients with vomiting, diarrhea and dehydration, we first determine the appropriateness of the housecall before responding. The doctor will ask questions to be sure that symptoms do not suggest a serious or life threatening emergency, in which case 9-1-1 should be called. An estimated time of arrival will be given to the patient at this time. The physician’s arrival will be subject to traffic conditions.

What We Bring and How We Treat

Our doctors carry antiemetic (anti-nausea) medications, including oral, sublingual, and injectable forms. Most patients will have their nausea resolved with sublingual (under the tongue) medication within minutes. Some will require an injection for these symptoms. Occasionally patients will have significant dehydration such that nausea persists until this is corrected. We always carry IV fluids for rapid rehydration in these cases. Once an IV is established by the house call physician, most young and otherwise healthy patients will begin to feel better within minutes. The IV fluid therapy is typically complete within 1 hour or so. Our patients usually express surprise and elation at how quickly they are feeling better.

The key to treating patients with vomiting and diarrhea is to rehydrate, rehydrate, rehydrate! Our goal is to bring our patients to a point where they can do this on their own. We usually will offer to leave our patients with anti-emetic and/or other meds for self treatment after our departure. When appropriate, we will encourage most patients to rehydrate with electrolyte replacement solutions such as Powerade or Gatorade. We usually bring these too!

While rapid rehydration is safe for young and healthy patients, people with certain medical conditions or who are age-enhanced may require slow rehydration, sometimes over 1-2 days. These patients will usually be referred for hospital treatment, unless round-the-clock home skilled nursing care can be arranged.

Modern Housecall Technology

In some cases, our mobile emergency physician will carry an iStat, a handheld device that is able to perform rapid blood testing on site. A few drops of blood and a few minutes are all that are needed before results are available. Glucose, electrolytes, including sodium, potassium and chloride, CO2, BUN and creatinine (kidney function), calcium, hemoglobin and hematocrit are the tests that we currently offer in this way. Your housecall physician can draw blood and transport it to any hospital lab for urgent processing as well. Instant urinalysis dip testing and urine pregnancy tests are also carried.

Hospitalization

On rare occasions, after the initial examination by our house call doctor, it may be determined that the patient has a more serious situation requiring evaluation in the hospital emergency department. Our doctor will help facilitate transportation arrangements if needed, and will communicate with the hospital emergency physician directly to help facilitate your care.

Modern Housecall Doctors

Our physicians are all experienced emergency medicine practitioners. We are licensed to practice medicine by the California Board of Medicine. We are Emergency Medicine board certified or eligible, are residency trained in emergency medicine, have rock-solid reputations, and our patients tend to like us. Our online reviews are top quality, and patients frequently express their gratitude for the work that we do. As emergency physicians, we believe that patient safety should be highly prioritized when it comes to housecall practice. As emergency physicians we are comfortable evaluating and caring for seriously ill patients. This fact means that you are in excellent hands when being cared for by one of our physicians.

Please realize, however, that we are NOT an emergency medical service. Seriously ill or injured patients should call 911 or go to their nearest hospital ER.

Paperwork and Insurance

Our treament will be documented in detail during the housecall visit. A superbill will be completed for all cases, which includes patient information, a medical report, diagnoses, treatment rendered, and itemized charges. A copy of this form will be given to the patient and may be submitted to the insurance provider by the patient for reimbursement.

For all PPO and HMO insurers, we are considered out-of-network at the current time. For PPOs, the annual out-of-network deductible that remains unmet will usually determine your out-of-pocket expense. PPOs typically cover up to 80%. HMOs may cover up to 100% if they have no nearby contracted facilities. Policies vary, so always check with your insurer directly for details about your coverage.

Health Savings Account (HSA) and Flexible (FLEX) spending account credit cards may be used for our services.

For patients with travel insurance (visitors to the USA) we may agree to bill your insurer directly if coverage for our service has been pre-authorized.

Payment for our services may be made with cash or major credit card at the time of service.

Our Fees

For patients with mild symptoms such as mild nausea without vomiting, and where no injections or IV fluids are required, our fees are limited to the basic housecall charge and any dispensed meds. Typically this will start at $265. Medications usually run $10-$80 for these problems. Patients may opt to have prescriptions filled by their pharmacy as well in order to use their insurance copay.

In some cases, afterhours, weekend or night service fees will apply. Travel fees are included when our physician must respond to distant areas.

Injections, IV fluids and lab testing will add to the cost, usually ranging from $100-$800, rarely more.

When the initial request for service is made, an estimate will be offered, and will usually include a range since we cannot usually know beforehand exactly what the patient will need in these situations involving vomiting, diarrhea and dehydration. Some directly paying patients opt to start with our convenient assessment, then if it appears that they will require more extensive care, they may opt to have their insurance billed directly by going to a nearby ER.

For patients without insurance, our IV rehydration services are always substantially less than hospital emergency treatment.

Instruction and Followup

At the completion of the housecall, detailed instructions are always given, and our patients always know that they can call us anytime, 24/7, with questions or problems that arise. Further simple telephone consultations as ongoing care for the same problem are free of charge.

Conclusion

Vomiting, diarrhea and mild dehydration are excellent reasons to request a house call

Remaining at home with these symtoms is far more comfortable for the patient than traveling and sitting in a waiting room

Symptom relief is usually amazingly rapid once our doctor has arrived!

Costs for housecall services for these problems varies depending upon many factors, can get pricey for the sicker patient, but is always less than the ER for those who have no insurance. Our services are insurance reimbursable in many cases. FLEX & HSA accounts may be used, and we accept most traveler insurances.

We always provide our patients with 24 hour telephone access for followup questions or problems.

We are the easiest urgent care service that you will find!

Sore throat is one of the most common reasons that patients call us. For those who have never utilized our services, this is how it works when we are asked to treat a patient with a sore throat.

Why a house call for this problem?

Patients usually call us because they are busy and cannot wait for a delayed appointment time with their doctor. They often do not want to travel, sit in their doctor’s waiting room, then stop and potentially wait at the pharmacy for prescribed medicine. Many patients with sore throat feel feverish, weak, fatigued, and simply want to stay at home where they are comfortable and can rest. Some patients experience nausea and/or vomiting with their sore throat and prefer to stay at home where they may have easy access to the bathroom. Patients may have severe pain so that they are unable to swallow food or liquids. These patients may become significantly dehydrated, so that travel becomes difficult due, again, to weakness and fatigue. Many of our patients tell us that they do not want to be exposed to other infectious patients in public waiting rooms. Patients with serious or life-threatening conditions should always go to their nearest emergency department or call 9-1-1.

When a housecall is requested

When the patient, or requester calls us, a doctor will ask them questions to immediately determine the appropriateness of the house call. If the physician feels that the patient would be better served in the ER, the caller will be advised of this. Once both parties agree to the house call response, the patient’s name, location, and contact information will be recorded and an arrival time will be estimated. In most cases, the doctor will arrive within the hour, however arrival is always subject to traffic conditions, and any prior scheduled requests. Appointments are made on a first-come-first-served basis.

What we bring

When the doctor arrives at the patient’s home, hotel or workplace, he or she will arrive with whatever medications, equipment or lab tests are needed to evaluate and treat the patient so that after the visit is complete, the patient will be able to remain at rest. The patient always has the option to have prescriptions filled at a nearby pharmacy of choice.

The medical evaluation

For sore throats, usually a quick history and physical exam are all that are needed. The doctor carries a stethoscope, thermometer, pulse oximeter, sphygmomanometer(blood pressure measurement) and otoscope to use for the initial exam. Occasionally a strep test may be performed, although this is usually not necessary. Instant influenza tests are usually carried by our house call physicians during the winter months.

Treatment

Antibiotics may be determined to be appropriate in many cases, and may be dispensed directly, or a written or telephoned prescription will be provided. Injectable antibiotics may be offered in some situations. Other medications may be required as well. Since many cases of sore throat are caused by viruses, not bacteria, antibiotics may be offered on a wait and see approach. With this strategy, the idea is to avoid antibiotics for a brief period of time, then to call in a prescription to the pharmacy if the patients symptoms begin to worsen or if no improvement occurs after a period of time. This approach is commonly used by many medical providers, and has helped to minimize antibiotic over-usage. Certain cases of sore throat with significant swelling may benefit from steroid treatment with prednisone. This medication may be provided for appropriate situations.

How we handle more serious cases of sore throat

Occasionally patients many be found to have a more serious cause of sore throat such as abscess. These conditions require immediate or urgent drainage procedures . These patients will require immediate referral to an otolaryngologist or to the emergency department. We will always facilitate these arrangements for the patient for your convenience and safety.

Mononucleosis

Sore thoat caused by mononucleosis is diagnosed via blood testing. Our house call providers can arrange for this evaluation through a nearby laboratory. The house call physician may offer to draw blood and then transport it to the lab for processing. In many cases this testing is best to perform at least 1 week after the onset of illness. The house call doctor will recommend the optimal strategy.

Insurance, paperwork, and payment

Once the examination is finished and treatment plan determined, a superbill form will be given to the patient. This form may be submitted to insurance providers for reimbursement if coverage is maintained. Payment for the housecall visit is accepted via cash, credit card, or invoice for pre-authorized insurance plans(traveler insurance plans). Flexible Spending Account (FLEX) and Health Savings Acount (HSA) credit cards may be used.

Fees

A typical house call for patients with sore throat is $265 within San Francisco before 5pm weekdays. For services during afterhours, nights and on weekends, an additional fee applies. Medications that we dispense are typically $20-$80, or patients may just pay their insurance copay by going to the pharmacy directly. Occasionally an antibiotic inject may be preferred and fees are usually ~$100-$140. Additional charges may apply for any lab tests that are done. Again, for most cases tests will not be recommended. Physician travel fees are charged for services rendered outside of San Francisco, unless the doctor already is nearby. A house call fee estimate is always provided at the time of the initial service request.

Followup anytime!

Detailed instructions will be given to the patient, and in all cases patients may call us anytime, 24/7, to clarify instructions or discuss further care.

Even the typical after hour clinic can be jam packed with patients, and waiting times can be excessive. The physician house call provides a far more user friendly alternative to the after hour clinic. These services may be available for patients of all ages with almost any urgent care problem. Instead of having to endure endless wait-a-thons in the ER or after hour clinic, patients rest in he comfort of their own home or hotel room while the doctor is enroute.

For patients with painful conditions, or those with weakness, fatigue, nausea, vomiting or diarrhea, and many other conditions, remaining at home instead of sitting in the waiting room of an after hour clinic or ER can truly transform the comfort level of the patient. For many conditions, such as generalized infections, rest is a requirement for healing. For patients who need rest, it is counter-productive for them to have to travel to the after hour clinic, sit endlessly in a waiting room, then again wait during treatment, then travel home, stopping along the way at a pharmacy to wait in line to submit prescriptions, then wait further for the prescription to be filled, then finally return home.

It is likely that many patient’s condition are actually worsened by all of this effort and stress. In the United States, doctors of the past understood this well. Only recently have physicians renewed their interest in house call medicine as a kinder, gentler way of rendering acute or urgent healthcare.

While many geriatric physician house call practices have sprung up nationwide during the past decade, a handful of innovative services, such as that of Urgent Med Housecalls, caters to patients of all ages. Urgent Med Housecalls, based in San Francisco, offers the ultimate user friendly experience for patients wanting to avoid the after hour clinic. Care is provided by experienced emergency physicians who bring medications, IV fluids, injections, stitches, splints, instant lab tests, even x-rays and more to the patient.

These convenient services are now offered throughout the San Francisco Bay Area, south to the Monterey Peninsula. Services are available 24 hours a day, 7 days a week. Physician house call services are transforming the way healthcare is offered in America. Patient centered medicine has returned and is here to stay.