WhiteCoat

The Case of the Crazy Rabid Squirrel

Who (if anyone) is to blame?

Man and squirrel fight it out in man’s driveway. Squirrel scratches him twice, man runs inside grabs BB gun and plugs squirrel ala Elmer J Fudd. Man then calls health department for advice about what to do. Health department tells him to go to ED for rabies shots. After waiting for 2 hours the following day in the ED, the patient is told that squirrels don’t carry rabies in the United States and he doesn’t need the rabies shots. Later he is billed $692 for the emergency department visit and doesn’t want to pay the $382 deductible.

The patient stated that “the health department and the hospital should get together and straighten it out.”

Should a hospital and physician be responsible for getting payment from third parties when patients don’t like the medical advice they have received? Isn’t that kind of like someone in a restaurant telling the owner to get payment from the noodle maker because the patron didn’t like the spaghetti?

48 Responses to “The Case of the Crazy Rabid Squirrel”

  1. Anonymous says:

    “Later he is billed $692 for the emergency department visit”

    So 15 seconds of a doc’s time after 2 hours of waiting costs $692? I’d like to see the breakdown of that cost, because that’s inexcusably high especially since no services were performed.

    And your analogies suck WC. Quote more than just the last line of the article: “I went there because of a recommendation from the health department and then the hospital really did nothing.”

    While the dude in this story does make a valid point, the health department’s job isn’t to give out medical advice (prove me wrong otherwise). As such, it falls on you to decide whether or not to go to the ED, and the responsibility for paying incurred costs falls on you.

    • ThorMD says:

      What makes you think no services were performed? The patient was triaged, vital signs taken and an H and P were done by the doctor. The ER is expensive and has a huge overhead. IF he wants a bill of 100 bucks, he should go to his doctor’s office.

      I see patients all the time who try to make appointments to see their MD and are sent to the ED because the secretary says “well, it could be XXXXX, and the ED can handle it better”. It’s usually never XXXXX and the patient gets made because the primary doc could have taken care of it in the first place for less money. Doesn’t mean I shouldn’t get paid.

    • WhiteCoat says:

      C’mon. In retrospect, this analogy wasn’t the best. Then again, right after I put up this post, I put up another post saying that South America is a country.
      But all my analogies suck? You’re killin me.

      I agree that the costs for medical care are high and that is precisely why I think there has to be transparency in pricing in medicine. If the patient walked into the emergency department and, before he even registered, was told that the visit would cost $700, he may have decided to go back and consult Dr. Google after all.

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  3. Anon says:

    In this case, a quick search with Dr Google may have saved some time.

  4. Celeste says:

    The guy didn’t even go to the hospital until the next day. He had plenty of time to ask Dr. Google if squirrels carry rabies. He chose to go to the ED. He received service, even if he doesn’t think it was valuable, and he owes. The end.

    • tish says:

      we are assuming that everyone has access to the internet. or even knows how to use such internet…we don’t know how old this man was…my grandfather can’t even turn on a computer let alone does he know what Google is or how to use it..

  5. Dial Doctors says:

    I agree with Celeste when she says that the patient had enough time to consult online. He could have also called his primary physician and asked for advice. It’s called telemedicine and most doctors do it inadvertently.

    If you tell any secretary the word rabies she will pass the call. I’m sure most doctors may even squeeze you in for a rabies shot. He knows the consequences of denying you care could be disastrous.

    ThorMD is also correct when he states that he most likely received some sort of service before he saw the ED doctor. The patient owes and he will have to pay.

    This is $382 lesson on calling your physician first before making rash decisions.

  6. Teresa says:

    I agree. The emergency department is not the place to take something that you felt could wait until the next day. Nearly by definition, that’s not an emergency.

  7. ndenunz says:

    @ ThorMD: Don’t your think $692 is a bit excessive for triage, vitals and an H&P?

    • min says:

      ndenunz you want the emergency services available 24/7 or just alternating Tuesdays from 1-4?

    • hgf says:

      i bet she/ he doesn’t because it’s ED after all
      7 hundreds with insurance basically for h and p
      how big was the squirrel? what color? female or male? how many squirrels have you met in the past year?

    • ThorMD says:

      ED’s are the most expensive way to provide primary care. I feel for the guy because the person who answered the phone at the Health Department was wrong and his primary doctor may or may not have also told him to go to the ED. But that’s what ED’s cost. It’s costs money to have the place open 24 x 7, stock it with equipment and drugs needed for every conceivable emergency, staff if with qualified nurses and doctors and enough ancillary staff to make it run. I can assure you the doctor didn’t get $692 for 10 minutes of work. And I wonder if they guy had a $0 bill (insurance paid for all of it) if he would have cared at all.

      Why do you think that every politician has latched on to the fact that they want to decrease health care costs by keeping people out of the Emergency Department?

  8. Derrick says:

    ndenunz – of course $692 is excessive… but didn’t you see that this patient is not going to pay it, he disputes the charge. Oh, and the other 3 patients seen that hour aren’t paying either (they are homeless, or disagree with THEIR charges) and the 2 patients in the next hour disagree as well. Therefore when the 7th patient in 2 hours gets HIS bill for $692 and actually pays it, he is paying for the whole lot of them…

  9. Marilyn says:

    I’d sure like the ED docs to pay my daughter-in-law’s bill. She was having abdominal pain and endless diarrhea. They gave her antibiotics. More pain, more diarrhea. The bloody kind. Long story short, after 4 emergency visits, CT scans, blood tests, ultrasounds and x-rays (go home, we can’t see anything), a 12-pound weight loss in three weeks, inability to finish her term in school ($4,500) someone got the bright idea to take a stool sample.

    C. Diff.

    If someone had done that first, she wouldn’t have lost a very expensive term in school and wouldn’t have over $10,000 in medical bills which she is going to be paying off for YEARS. Shouldn’t the doc who sent her home with bloody diarrhea take some responsibility?

    • Pudortu says:

      If she had gone to her primary care doc (like she should have for this CHRONIC NONEMERGENT situation), then someone with CONTINUITY may have solved her problem with minimal cost. Get some common sense and stop blaming everyone but your daughter’s laziness / idiocy for her problems.

      • MamaOnABudget says:

        That’s not fair. You don’t know if her primary care told her to go to the ED. I know when I was under the care of a GI, I had extreme pain and needed to be seen for pain assessment. I called the office (2 hours away – closest GI) to be told that no one was in – the GI and his PA were away at a week long conference. They called the GI, who told me to go to the ED. However, that wouldn’t have done me any good… the local ED/hospital didn’t have any GIs on staff… hence the 2 hour drive. And if I drove out to their hospital… no GI on staff that week!

        If the patient calls their doc and the doc says to go to the ED, shouldn’t they keep going back to the ED if the symptoms persist/get worse? That’s what my discharge papers said (return to the ER if symptoms persist or get worse) when my primary care physician sent me there for rehydration with flu when pregnant. And that’s something that could have been handled in the doc’s office, too – but was passed off to the ED by the doc.

      • Marilyn says:

        Her primary care SENT her to the emergency department.

    • hawk says:

      Marilyn

      I understand you frustration, but the fact is that c diff is not something that er’s routinely screen for. When I was a resident, we were always told that if a test cant be resulted in a few hours, it is a test worthy of the PCP. I have not, in my entire 10 year career, ordered a c diff on a pt, the simple reason being that I am then responsible for the results of that test, even if they take a day or more to come back, and then I would be responsible for getting in contact and suggesting a course of action. that type of service is called primary care, and it is not something that ER docs are trained to do, and it is not something that we WANT to do.

      To be fair, I do tell people that c diff is a possibility,a nd I refer them back to the PCP.

      As far as DC instructions that say if your symptoms get worse, come back to the er, that is boilerplate, all instructions say that as it helps with liability issues. Thank the lawyers. you may end up coming back and being re-evaluated time and time again for something that may be found in a quick 10 minute trip to your PCP, but as I explain to those I am teaching, out job in the er is not to diagnose, it is to rule out. We make sure there is nothing there that is going to kill you in the next few days. after that, your PCP is the one that needs to take some responsibility for your care.

      You can blame the er doc all you want, but you are expecting him to have done something that is not done in an er, and the fact you had to go back three times before somebody decided to take up the slack of the PCP and do this test shows that it is not something that is done. I wold send a thank you letter to the last guy, who decided to take some PCP work onto his shoulders and run that test.

      • MV says:

        Sorry, but if the discharge papers say to return to the ED if X happens then you certainly cannot blame the patient for returning to the ED. Or the lawyers.

        If you have to use discharge instructions to CYA then perhaps the lawyers are involved for a very good reason.

        There seems to be a double standard involved with patients. They are expected to know and be involved in their care but if they are too involved or question their care that is bad. Where that line is drawn varies widely. Ultimately, I have concluded that if you get really sick you will be subject to massive costs, anything but a basic office visit is going to hurt the wallet and no medical professional can be soley relied on for medical advice.

  10. Amy says:

    I agree with the commenters who think a $692 bill for this case is unreasonable.

  11. Essay says:

    OK. Time for a little vet talk here. First of all, while squirrels are very infrequently found with rabies, they’ve been given no special exemption from the disease. Second of all, when in doubt, the state veterinary lab should receive the carcass and test the brain for rabies. No prophylaxis should be given until the test is completed. Thirdly, even if rabies can be ruled out, there are still quite a few other zoonotic diseases that need to be taken into consideration; I remember seeing a rather spectacular picture of Sporothrix schenckii contracted from a squirrel bite when I was in vet school.

    The emergency room visit was necessary, even if the reason given wasn’t necessarily accurate. The health department should be somewhat ashamed of themselves for giving advice they way they did, however.

  12. B.RAD says:

    @ Marilyn

    I feel for your daughter and I’m glad the problem was eventually solved. However, Pudortu is correct in saying that the E.D. is not the place to evaluate nonacute situations. A referral to an internist or gastroenterologist after the first E.D. for follow up would be appropriate. Lack of continuity in physicians, nurses, having available past pertinent medical/surgical histories, medications, previous test results (especially when multiple E.D.s are visited) and following up with the patient, all make the emergency room the WORST place to go for these types of problems.

    • Marilyn says:

      As I replied above, her primary care passed her off to the emergency department. And she was told “if it gets worse, go to emergency department.

      She was following their instructions.

      They did indeed set her up with a GI specialist who wasn’t going to see her for another month.

      No none wanted to deal with a 26-year old college student who they thought was stressed by her workload, hypochondriac, or, worse, a closet anorexic. They accused her of such.

      They were sure quick to test for all the STDs, they couldn’t have done a stool sample?

      I stand by my argument that in this case they blew it.

      • Derrick says:

        Marilyn, I have to disagree that the ED blew it – the PCP may have blown it, but the ED did not. The role of the EMERGENCY doctor in the EMERGENCY department is to identify and treat an EMERGENCY. The fact that your daughter did not die or lose a limb or lose any other vital organs suggests that the EMERGENCY doctor looked and did not find any emergencies that required treating. The reason the PCP sent you to the ED was to rule out any emergencies.. once that was done, the PCP should have stepped up and found the non-emergent cause of her symptoms.

      • Marilyn says:

        Derrick…

        Actually, that’s right.

        Back to the squirrel, as I understand it, an animal bite is not an “emergency” and the guy could have consulted with urgent care for a lot less money.

        Heck. Even Dr. Internet could have told him whether or not squirrels in his area carry rabies. ;-)

      • CJ says:

        Derrick, I have to disagree with you. First of all, PLENTY of patients are treated in the emergency department for non-emergencies. I’m not just talking about patients who abuse the emergency department for things they should see their PCP for (colds, med refills, etc.), but lacerations, broken bones, and other conditions that while technically aren’t emergencies, are treated in that setting. Emergency department physicians are still physicians. They don’t just look for an emergency and then throw you out the door if you’re not dying. I most definitely don’t know the specifics of this case, but they can at least try to determine the cause of the diarrhea (have you taken any antibiotics recently?). Not saying they didn’t do that, but saying that their job is over after they determine it’s not an emergency is oversimplifying the situation.

      • Hueydoc says:

        Was it 4:30 PM when you called your primary doctor and he sent you to the ER ?
        Seems to happen a LOT here .

      • Derrick says:

        CJ – sure, we treat a lot of non-emergent things in the ED, and we do our best as physicians for the most part. However, we are not and MUST NOT be tasked with providing perfect outpatient non-emergent care for chronic issues. Your examples of broken bones, lacerations are ACUTE problems that require prompt intervention – hence the 24 hour nature of the ED. These examples are different from problems that have been going on for weeks or months and should be addressed by a primary care physician.

      • Marilyn says:

        8:30 PM, Saturday night. Urgent care closed.

        Patient has been sick since early April (nearly three months), and getting sicker, has lost more than 10% of her body weight, going from 112 to 98 pounds in two months.

        Bloody diarrhea getting bloodier, patient unable to walk without assistance because she cannot move without starting to lose consciousness.

        Is it an emergency yet? Or can it wait until Monday morning?

        The doc who told her it was an ovarian cyst and would get better in a couple of weeks, the same doc who gave her the antibiotics (and SHOULD have been attentive to the fact that C.Diff is frequently an after-effect of antibiotic therapy) blew her off.

        I’m not opposed to paying for emergency visits, and paying the high price. It’s worth it for the skill offered there.

        But someone (and, now corrected, not the ED doc) cost this girl unnecessary money and unnecessary suffering. I am not a believer in trying to profit off of suffering, but the doc who caused the delay ought to absorb the EXTRA cost that could have been avoided. This could have been nailed down for under $1,000. Now the bill is ten times that.

  13. practicemgr says:

    doesn’t want to pay the $382 deductible.

    Just saying that patients not wanting to pay their deductibles for any sort of medical services rendered isn’t isolated to the ED….

  14. WhiteCoat says:

    My take on the scenario is this:

    Essay (or other vets), correct me if I’m wrong, but rabies can’t be transmitted by scratches, only by bites, correct? Unless the squirrel was biting its nails or something, there shouldn’t have been a problem.

    I once heard medical care be compared to prostitution (I’m teeing this up for all you doctor haters out there – and this theory also applies to the practice of law, so Matt better not wise off): The value of services is worth much more before they are performed than after they are performed.
    How much is it worth to you to determine whether or not you should be treated for rabies and, if so, how to be treated? Which leads me to my next point.

    Prices should have been disclosed up front. How can a patient make an informed decision about whether the services provided are worth what is being charged if the patient doesn’t know what the services cost?

    Unfortunately, hospitals are forced to subsidize the care of many patients who can’t afford to pay and charging higher prices to those who can pay is one of the few ways they can stay solvent.

    The emergency department wasn’t negligent in providing its services and should be paid. We can’t just withhold pay from someone because we don’t like the services they provide. Your boss can’t do it if he doesn’t like your work. You can’t do it with taxes if you don’t like the government’s services.

    Finally, the whole scenario highlights the idea of who patients should trust and how much they would be willing to pay to get an answer from someone they trust. Free advice is often worth what you pay for it.

    • Essay says:

      Rabies is most commonly transmitted by bites, but not exclusively. There are plenty of aerosol transmission cases in the literature. Most of these involve cavers, but there is also one probable aerosol incident that involved a very young child in the DC area who was not bitten but who had a bat found in her room.

      Saliva is the usual culprit, but you don’t need to be bitten by an animal to get saliva in the wound. Mammals wash themselves by licking, and saliva on the hair or on the nails can transmit rabies. Simply handing a rabid animal, alive or recently dead, puts you at risk.

      Since the disease is virtually 100% fatal, and since the treatment is virtually 100% foolproof, if there is a genuine risk of rabies exposure, then post-exposure prophylaxis is in order. The largest group PEP I know of was in New York in the late 90’s, when just under 30 people were given PEP because of a single rabid cat. Most were not bitten, but all had handled the cat.

  15. Luann says:

    Yes, a scratch is enough to pass on rabies. However, it is highly unlikely that a squirrel would have rabies.

    I agree that the abd pain with diarrhea is not an emergency UNLESS it was a SEVERE pain that doesn’t let up or localized pain. Even then, a patient’s perception of SEVERE pain is questionable at best.

    I know of a patient that, on the advice of a phone triage RN who told him to call 911 for chest pain…refused to pay the ambulance ride to the hospital because the nurse advised him.

    People just don’t use common sense nowadays.

  16. SeaSpray says:

    I’ll come back to read the comments.

    Our ED was clear about NOT doing third party billing stating it was up to the patient to work the billing out.

    But, if I didn’t know what I know about our area from working in ED registration…that private docs send patients to the ED, I might’ve wanted to go to a private doc first.

    And if I didn’t know about squirrels not being rabid, i would’ve been afraid of contracting the disease ..thus would’ve gone to gone to ED per health dept’s advice.

    I did have the rabies series because of a potential bat bite. I had the marks, never saw the bat, but had reached into heavy rug left on line over weekend. we have bats flying in yard and over pond, etc. It absolutely looked like what I saw on some patients that summer and since I knew they gave the vaccine ..even if a bat flew out from a patio umbrella with no contact, I didn’t want to chance it. I waited until very last day too.

    And I know we discussed why squirrels can’t carry rabies, but don’t recall why. if not already addressed in comments, it seems logical that they could because they are animals. ???

    I scared myself all week googling about bats and rabies. Boy, those South American vampire bats are scary ..leaving one to bleed to death.

  17. tish says:

    $600+ for triage and to be told that his two hours waiting was actually a waste of time?

    Are you serious WC about “getting paid”? If your child was in college and didn’t have medical insurance would you say to your child “well the doctors have to get paid”. Come on…bill him but please give me the break down of taking vital signs.

    I couldn’t see that trip costing more than $100 TOPS
    give me a break!

    • WhiteCoat says:

      This is why we need transparency and free market medicine.

      If someone was willing to see you within 2 hours of your decision to seek medical care and provide that care to you for $100, and you trusted the advice of that person, then there’s not a problem.

      However, if no one was willing to provide those services to you for that price, then you would need to decide whether it was worth more to you to pay nothing and incur the risks of developing rabies (whatever those risks might be), or pay the asking price to get an answer from someone with experience in the issues.

      $600 is a lot of money, and I agree that it seems excessive for the perceived services, but it isn’t just about the doctors getting paid. It’s malpractice insurance. Hospital building costs. Fixed costs such as rent/heat/water/waste disposal, etc. Costs to hire nurses, techs, and secretaries that are there 24/7. You’re not just paying the doctor’s salary, you’re paying to keep the whole hospital afloat. And think about how much it costs to keep a hospital running – especially when subsidizing the care of patients who do not pay their bills.

  18. B.RAD says:

    @ CJ

    I agree that conditions that are not true emergencies are treated in the E.D. But should they be? The enormous cost of care rendered here for all these nonemergencies is one of the main reasons the outlook for health care in the U.S. is not so good. Aside from long wait times, taking resources away from critically ill patients, taking all comers (as mandated by law) puts a huge burden on our front lines of care for reasons I stated in my post above. I’m not sure who you can point the finger of blame–the PCP for sending patients to the ER when they can very well treat them in the office–the patient for using the E.D. as a personal clinic–or just the mentality of our society of getting things fast and cheap. An outpatient workup is appropriate for a patient with diarrhea, one that requires follow up. If they go to the E.D., they’re going to a a very expensive test (CT scan of abdomen/pelvis) that rarely pinpoints the exact cause of diarrhea bacause the E.D. doc feels he/she has to do “something”, and a CT scan if the one tool that is available.

  19. hawk says:

    Marilyn

    I understand you frustration, but the fact is that c diff is not something that er’s routinely screen for. When I was a resident, we were always told that if a test cant be resulted in a few hours, it is a test worthy of the PCP. I have not, in my entire 10 year career, ordered a c diff on a pt, the simple reason being that I am then responsible for the results of that test, even if they take a day or more to come back, and then I would be responsible for getting in contact and suggesting a course of action. that type of service is called primary care, and it is not something that ER docs are trained to do, and it is not something that we WANT to do.

    To be fair, I do tell people that c diff is a possibility,a nd I refer them back to the PCP.

    As far as DC instructions that say if your symptoms get worse, come back to the er, that is boilerplate, all instructions say that as it helps with liability issues. Thank the lawyers. you may end up coming back and being re-evaluated time and time again for something that may be found in a quick 10 minute trip to your PCP, but as I explain to those I am teaching, out job in the er is not to diagnose, it is to rule out. We make sure there is nothing there that is going to kill you in the next few days. after that, your PCP is the one that needs to take some responsibility for your care.

    You can blame the er doc all you want, but you are expecting him to have done something that is not done in an er, and the fact you had to go back three times before somebody decided to take up the slack of the PCP and do this test shows that it is not something that is done. I wold send a thank you letter to the last guy, who decided to take some PCP work onto his shoulders and run that test.

  20. B.RAD says:

    “I couldn’t see that trip costing more than $100 TOPS”

    Please give ME a break! So it’s worth only a hundred bucks to be told by a qualified, board certified physician who works in a facility that’s open 24/7/365, has all the up to date equipment needed for all emergencies, a fully stocked pharmacy with pharmacist on call, has qualified personnel assisting, that after fully evaluation you, you in fact do not need the rabies vaccine, which consists of multiple injections?

    How about this one. How much do you think you should pay if you take your young son, who has a severe sore throat, trouble breathing and fever,into the E.D. at 2:30 am, and you’re terrified because your neighbor’s daughter had the exact same symptoms and died from epliglottis last year, and after an exam by the physician, you’re told it’s just strep throat? Then compare that amount to how much you would have to pay a plumber and clean up company to come to your home on Christmas eve because you just discovered you’re pipes burst and entirely flooded your basement.

  21. kg says:

    Essay says: “the disease is virtually 100% fatal…if there is a genuine risk of rabies exposure, then post-exposure prophylaxis is in order”. Agreed. But you can’t afford to wait 4 days for the carcass brain exam results from the state health dept/lab. (Or can you?) If it’s worth it to you to follow up on, the post-exposure prophylaxis consists of rabies immune globulin (9ml for a 156 lb person) and then 5 rabies vaccines over the next month. The immune globulin is only kept at hospitals as far as I know; it is extremely expensive and even the 6 urgent care centers in my town do not keep it, so very unlikely that a PCM could squeeze you in for that.

    And for your viewing pleasure:

    Bat Bite Visit 1, Summer 2009:
    Level 3 Exam Emergency Dept $145
    Inj Ther (injecting immune glob & vaccine) $40
    Rabies Vaccine (Imovax) $334

    Visits 2-5:
    Treatment/Infusion Room $135
    IM injection $25
    Imovax $334

    It appears that I and my insurance (thank God for my insurance!) were not charged for the immune globulin. Maybe it comes out of a federal public health fund? (Like the Tamiflu stockpile?) At the vaccine-only visits, the fee for a nurse to administer a vaccine was $25. The fee for use of an outpatient surgery room for 20 minutes (during non-surgery hours) was $135. Those 4 visits could perhaps have taken place at a physician’s office. Cost for a specialist to evict the bats from our house: $3000 out-of-pocket, with a 1-yr guarantee.

    (Oh and squirrels are rodents, and rodents somehow don’t generally carry rabies. I think.)

  22. Tom says:

    In reply to Dial Doctor, Where I am from, doctors’ offices will just tell you to go to the ER no matter what you ask of them. With that said, Knowledge is power, so if the similar thing happened to you, with say a a legal matter, you might not know that you had been inconvenienced, overcharged, and taken advantage of for until after you followed the lead of poor advice.

  23. That’s right Tom, I’ve been thinking the same as you’ve thought that if we came across to such situation, why not do it the legal way, we just don’t want ourselves to get robbed by those physicians.

  24. michelle says:

    My friend’s son was bitten by a strange dog that disappeared. He was told in his area that the only place to administer rabies shots was the ER. He tried going to an urgent care first. So, I don’t fault him for going to the ED – it sucks his deductible is so high. Too bad in this case he didn’t check with his PCP first and avoid the ER.

  25. RussM says:

    The cost does seem a bit high, but since it kept him from getting the expensive series of injections, was probably worth it.

    I would not have treated either, but that is based on knowing my area, knowing (googling) squirrel rabies rates (low to zero), knowing rabies is rarely transmitted except by bite, I think it is safe for not treating. Lots of illnesses could be highly lethal, but we still don’t automatically treat them all. The patient made the decision to wait until the next day and not call his PCP. THe health department will almost always refer to a doc/ED for evaluation. THey are not giving medical advice, they are referring to someone who can.

    To Marilynn,

    As an ER doc, I am sorry for what happened to your daughter, but that sometimes happens. C-diff can be self limiting in some situations, and probably NOT the underlying cause of the overall illness. We are now doing some testing in our ER, but only because we have quicker turn around times for the test. It is the ER job to rule out the serious stuff as best as we can. We cannot always figure it out. I tell people quite often that I don’t know what is wrong with your family member, but I am confident that it is not x,y z for these reasons. It is important to follow up with your primary doc and RETURN if WORSENS. 2 or three visits for a worsening problem equals admission to the hospital for a second set of eyes to re-evaluate.

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