I wish blood pressure did not exist.

[thegenius]

I wish the entire concept of blood pressure did not exist. I wish nobody knew it was something to measure. They might know that blood flows around the body, but are totally unaware of the entire concept of blood pressure.

Or I would be happy if it was unmeasurable. As long as it is not a vital sign.

Our lives in the ED would be so much easier, I reckon.

I spent 10 minutes explaining to a patient why the blood pressure on the monitor of 193/179 is physiologically impossible and she was looking at me like I was from planet McDufus.

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[gro2001]

I wish the entire concept of blood pressure did not exist. I wish nobody knew it was something to measure. They might know that blood flows around the body, but are totally unaware of the entire concept of blood pressure.

Or I would be happy if it was unmeasurable. As long as it is not a vital sign.

Our lives in the ED would be so much easier, I reckon.

I spent 10 minutes explaining to a patient why the blood pressure on the monitor of 193/179 is physiologically impossible and she was looking at me like I was from planet McDufus.

Why not just ask the nurse to do a manual? Or if you have time, do one yourself? It would both reassure the patient and prevent the crazy reading from being logged in to the system. Patients get that equipment can give off wrong readings. A physiology based explanation though might just make them feel stupid, and no one likes feeling stupid.

If I was a lay person and a doctor told me something I was seeing/experiencing (even if I was mislead by faulty equipment) is impossible, I think I would react in a similar way to the way the typical ER doc reacts to the "things consultants say are impossible but happened thread".

 

[Angry Birds]

I love vitals. Couldn’t love them more. That includes blood pressure.

And yeah just recheck it. No biggie.

“That looks pretty high. A lot of people have what’s called White Coat Hypertension, meaning their initial blood pressure is really high due to the stress of seeing me (pause for laughs). Let’s recheck it in a bit.”

 

[southerndoc]

Wasn't there a time when you needed a prescription to buy a machine? Not readily having access to a BP cuff would be great for a lot of our patients. Nothing like someone coming in at 4 am because their blood pressure is high. "Why did you check it? Did you set an alarm to wake you up to check it?" "No, I had a nightmare." "That explains your blood pressure. See your pcp."

 

[hundreddaysoff]

Patients not understanding blood pressure, I can understand. If they had read the book, they wouldn't be my customer, and I like customers. Call me insecure?

RNs dropping everything and running up to me and going "¡DO YOU WANT TO GIVE HIM SOMETHING FOR HIS 183 SYSTOLIC!" re a completely asymptomatic man, not so much.

Even some experienced RNs do this. After I've educated them, even. "Treat the pt not the number" was one of the first things they taught me in med school; still don't understand why this logic suddenly goes out the window for some otherwise very smart RNs re BP. Maybe it's some secret RN hospital protocol stuff?

 

[thegenius]

Why not just ask the nurse to do a manual? Or if you have time, do one yourself? It would both reassure the patient and prevent the crazy reading from being logged in to the system. Patients get that equipment can give off wrong readings. A physiology based explanation though might just make them feel stupid, and no one likes feeling stupid.

If I was a lay person and a doctor told me something I was seeing/experiencing (even if I was mislead by faulty equipment) is impossible, I think I would react in a similar way to the way the typical ER doc reacts to the "things consultants say are impossible but happened thread".

She had multiple normal(ish) ones and the the cuff slipped a little and she got the abnormal BP reading. And I did adjust the cuff and the subsequent reading was OK. This was more a commentary on the increasing amount of annoyance talking about blood pressure in the ED, and how all of our lives would be better off it is was impossible to measure.

 

[Stagg737]

Maybe it's some secret RN hospital protocol stuff?

It's no secret, just MEWS criteria and protocols surrounding it. At least once they're admitted it is, idk if that applies in the ED as well...

 

[GonnaBeADoc2222]

Patients not understanding blood pressure, I can understand. If they had read the book, they wouldn't be my customer, and I like customers. Call me insecure?

RNs dropping everything and running up to me and going "¡DO YOU WANT TO GIVE HIM SOMETHING FOR HIS 183 SYSTOLIC!" re a completely asymptomatic man, not so much.

Even some experienced RNs do this. After I've educated them, even. "Treat the pt not the number" was one of the first things they taught me in med school; still don't understand why this logic suddenly goes out the window for some otherwise very smart RNs re BP. Maybe it's some secret RN hospital protocol stuff?

Love the 8 notifications for BP 180/100 but ZERO people come to tell me about the other guy who is febrile with BP 80/50

 

[RustedFox]

Muggles and their blood pressure. They fuucking love it. No matter the situation, they fixate on it.

"Your father has awful pancreatitis and is in the throes of alcohol withdrawal. He's going to have a prolonged ICU stay and may need risky surgery to save his life."
...
"But his blood pressure is like, high. Never been that high before. What are you going to do about that ?"

 

[GonnaBeADoc2222]

Muggles and their blood pressure. They fuucking love it. No matter the situation, they fixate on it.

"Your father has awful pancreatitis and is in the throes of alcohol withdrawal. He's going to have a prolonged ICU stay and may need risky surgery to save his life."
...
"But his blood pressure is like, high. Never been that high before. What are you going to do about that ?"

One of my family members was recently in the ER. Another family member kept calling me to give me blood pressure updates almost every 10 minutes. I wanted to cry.

 

[Angry Birds]

Muggles and their blood pressure. They fuucking love it. No matter the situation, they fixate on it.

"Your father has awful pancreatitis and is in the throes of alcohol withdrawal. He's going to have a prolonged ICU stay and may need risky surgery to save his life."
...
"But his blood pressure is like, high. Never been that high before. What are you going to do about that ?"

Lol @ muggles. Hilarious

 

[theseeker4]

Love the 8 notifications for BP 180/100 but ZERO people come to tell me about the other guy who is febrile with BP 80/50

Or they don't take 5 seconds to tell you "Hey your patient in 8 was satting at 79%, so I threw some oxygen on them, wanted you to know". Find out hours later when going into tell the patient that workup was negative and they should be able to go home....Never documented the sat, never documented starting oxygen, nothing.

 

[RoyBasch]

"¡DO YOU WANT TO GIVE HIM SOMETHING FOR HIS 183 SYSTOLIC!"

I just like that this notification calls for the Spanish exclamation points. ¡Me encanta!

 

[scummie]

Muggles and their blood pressure. They fuucking love it. No matter the situation, they fixate on it.

"Your father has awful pancreatitis and is in the throes of alcohol withdrawal. He's going to have a prolonged ICU stay and may need risky surgery to save his life."
...
"But his blood pressure is like, high. Never been that high before. What are you going to do about that ?"

Or, the fascination with pooping. "Mom has not pooped since yesterday. She must be constipated. Do you think that's what's causing her XXXX? Are you going to give her medicine today for that?"

NO.

NO.

NO.

 

[Arcan57]

The other thing I hate about BP is that the pt risk stratifies as low risk for whatever complaint they presented with. BP is elevated and has no relevance to their complaint. Pt bounces back with something that elevated BP is a long term risk factor for and all the sudden everyone’s screaming about how BP wasn’t addressed on first visit.

 

[Angry Birds]

The other thing I hate about BP is that the pt risk stratifies as low risk for whatever complaint they presented with. BP is elevated and has no relevance to their complaint. Pt bounces back with something that elevated BP is a long term risk factor for and all the sudden everyone’s screaming about how BP wasn’t addressed on first visit.

It’s a good idea to make a note on discharge paperwork: “Please follow up with your doctor about your elevated blood pressure.”

 

[Xerxes1729]

All home blood pressure cuffs should have a 24-hour lockout. Once you take a measurement, it won't work again for 24 hours.

This would prevent me from having to write this HPI:

"The patient felt vaguely unwell. He took his blood pressure which was mildly elevated. Five minutes later, he still felt vaguely unwell, so he repeated his blood pressure. It was higher than the previous reading. He proceeded to retake his blood pressure every five minutes for the next half hour and is now very anxious and more hypertensive."

 

[GeneralVeers]

I hate these blood pressure patients. About 50% of them are never happy with an explanation and demand a medication to treat it. "The doctor we saw last time for his high blood pressure gave him something through the IV". I've just accepted that I can't make these people happy and will likely get a complaint letter the next day,

 

[thegenius]

I wish one could hit a "generate random blood pressure reading" button on those Phillips Monitors that will randomly, every 15 minutes, put out a blood pressure between SBP 110-140.

Focusing on poop can be somewhat irritating, but when I offer to stick my hand up their bungholio, they quickly accept a prescription for suppositories and enemas and they are out the door!

 

[hundreddaysoff]

It's no secret, just MEWS criteria and protocols surrounding it. At least once they're admitted it is, idk if that applies in the ED as well...

Wow, I never learned about MEWS. But mdcalc says that SBP <200 should get 0 points.

 

[Birdstrike]

I wish the entire concept of blood pressure did not exist. I wish nobody knew it was something to measure. They might know that blood flows around the body, but are totally unaware of the entire concept of blood pressure.

Or I would be happy if it was unmeasurable. As long as it is not a vital sign.

Our lives in the ED would be so much easier, I reckon.

I spent 10 minutes explaining to a patient why the blood pressure on the monitor of 193/179 is physiologically impossible and she was looking at me like I was from planet McDufus.

I feel your pain. This is why this was invented,

"Here's some clonidine 0.1mg po."

(30 min later)

"Oh, look your blood pressure has come down. [Everyone smiling now, doctor patient & nurse]. Imagine that. All better now. See your doctor as soon as you can to keep this down."

Bye.

Not saying it's right, but a lot of people treat the number, because the number treats the anxiety better than words. It's the wrong answer on the test, though.

 

[CajunMedic]

Or, the fascination with pooping. "Mom has not pooped since yesterday. She must be constipated. Do you think that's what's causing her XXXX? Are you going to give her medicine today for that?"

NO.

NO.

NO.

I got that “nugget” of information from one of my Attendings. “Everything in an elderly patient will come back to poop. If I poop, I’ll feel better, I passed gas, now I feel better, and so on...”

 

[Redrox]

Personal favorites was someone who was upset that the systolic was an odd number most of the day and the diastolic was mostly even on the home cuff and isn't that a dangerous mismatch ??

Also (not at the time) but hearing a nurse tell an asymptomatic anxious woman I'd successfully calmed down and reassured, as part of her discharge instructions to wake up every hour and recheck her blood pressure and come back in if anything changes.

 

[RustedFox]

Also (not at the time) but hearing a nurse tell an asymptomatic anxious woman I'd successfully calmed down and reassured, as part of her discharge instructions to wake up every hour and recheck her blood pressure and come back in if anything changes.

They (RNs) do this **** all the time. Discharging a patient with uncomplicated diverticulitis: "No seeds, nuts, or popcorn." STOP! This is folklore... myth... legend.... stop.

 

[namethatsmell]

If the asymptomatic HTN patient has been in the ED before, I look back at their vitals from prior visits and print it out to bring into the room when I meet the patient. I sit and listen and examine them. Then I show them the printout on how today their blood pressure is actually better than on other visits or in the same range, which it is 98% of the time. I've found doing this goes a long way to illustrate why it's not an emergency today.

 

[southerndoc]

First patient of the morning was a lady with hypertension that I spent 30 minutes talking to. Every question known to man, and couldn't understand why her blood pressure was high when she's never had high blood pressure before. She presented me with a log where she has taken it nearly every hour for the past month. For some reason, she thought this morning at 5:45 am was the time to be seen.

 

[bravotwozero]

Still better at 3 am on a Sunday though lol.


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[Birdstrike]

Prediction: Tomorrow, blood pressure will no longer exist.

 

[smq123]

I wish the entire concept of blood pressure did not exist. I wish nobody knew it was something to measure. They might know that blood flows around the body, but are totally unaware of the entire concept of blood pressure.

Or I would be happy if it was unmeasurable. As long as it is not a vital sign.

Our lives in the ED would be so much easier, I reckon.

I spent 10 minutes explaining to a patient why the blood pressure on the monitor of 193/179 is physiologically impossible and she was looking at me like I was from planet McDufus.

I also wish it were common knowledge exactly what defines a fever. "I took my temperature this morning, and it was 99.5. That's a fever for me."

<sigh>

 

[deleted109597]

I also wish it were common knowledge exactly what defines a fever. "I took my temperature this morning, and it was 99.5. That's a fever for me."

<sigh>

But what if I run cold?

 

[Angry Birds]

I feel your pain. This is why this was invented,

"Here's some clonidine 0.1mg po."

(30 min later)

"Oh, look your blood pressure has come down. [Everyone smiling now, doctor patient & nurse]. Imagine that. All better now. See your doctor as soon as you can to keep this down."

Bye.

Not saying it's right, but a lot of people treat the number, because the number treats the anxiety better than words. It's the wrong answer on the test, though.

This is the correct answer. Just give em Clonidine and see a couple more patients in the time that it would take to debate with anyone.

I also wish it were common knowledge exactly what defines a fever. "I took my temperature this morning, and it was 99.5. That's a fever for me."

<sigh>

Gotta be honest, I've seen plenty of people whose temp is <100.4 but still higher than normal, and they septic as duck. That cut-off of 100.4 seems arbitrary.

 

[smq123]

Gotta be honest, I've seen plenty of people whose temp is <100.4 but still higher than normal, and they septic as duck. That cut-off of 100.4 seems arbitrary.

That's fair enough, although I'm family practice. We spend a lot of time educating patients that if you're walking, talking, and thinking fairly normally, that rules out a LOT of acute life threatening conditions that they are convinced that they have.

 

[VA Hopeful Dr]

This is the correct answer. Just give em Clonidine and see a couple more patients in the time that it would take to debate with anyone.



Gotta be honest, I've seen plenty of people whose temp is <100.4 but still higher than normal, and they septic as duck. That cut-off of 100.4 seems arbitrary.

Most of our cut-offs are arbitrary. Is there really a difference between a sodium of 144 and one of 145? Of course not. But you have to draw the line somewhere.

 

[Stagg737]

Wow, I never learned about MEWS. But mdcalc says that SBP <200 should get 0 points.

I hadn't heard of it either until a few months ago, and while it can be useful it needs context just like (almost) every other data point we get. The first I heard of it was when I got a call from a panicking nurse on the floor that our patient had to be transferred to the ICU because they had a mews of 5 (at the VA new policy is that scores over 3 get transferred to PCU and over 5 goes to ICU). RR was barely over 20, HR in the 130's, nothing else abnormal. Turns out she had taken vitals on my pt with COPD exacerbation who was constipated 30 seconds after he'd finished pushing one out and he was still catching his breath. I literally had to spend the next 10 minutes explaining to her why this was not an emergency and that he was fine on the floor.

Have had to have several other battles with nurses about it since the hospital implemented the new protocol a few months ago and it's always because a patient's vitals briefly spike/tank to something abnormal and recover spontaneously without intervention.

 

[sunshinefl]

I hadn't heard of it either until a few months ago, and while it can be useful it needs context just like (almost) every other data point we get. The first I heard of it was when I got a call from a panicking nurse on the floor that our patient had to be transferred to the ICU because they had a mews of 5 (at the VA new policy is that scores over 3 get transferred to PCU and over 5 goes to ICU). RR was barely over 20, HR in the 130's, nothing else abnormal. Turns out she had taken vitals on my pt with COPD exacerbation who was constipated 30 seconds after he'd finished pushing one out and he was still catching his breath. I literally had to spend the next 10 minutes explaining to her why this was not an emergency and that he was fine on the floor.

Have had to have several other battles with nurses about it since the hospital implemented the new protocol a few months ago and it's always because a patient's vitals briefly spike/tank to something abnormal and recover spontaneously without intervention.

Haven’t thought about MEWS in a long time since I was a medical floor nurse. Just looked up the criteria and I’ve been managed, as an outpatient, with even a 7.

Edited to add: I just looked up the scoring criteria and scored for when I had pneumonia.

 

[UKEMdoc]

I've never given anything IV purely for hypertension. The problem with prescribing meds for bull**** is that it mis-educates the nurses/residents/patients that the patient actually needs something medical done. This is the same reason I discharge URTIs with advice to buy something from a pharmacist.

My normal strategy is to asked the patient what medication he missed this morning and tell him to take it. Advising diabetics that they need to take insulin also works for high blood sugars.

 

[bravotwozero]

actually it says verbatim in River's EM board review that 'giving IV medications to treat asymptomatic hypertension is a practice that should be condemned'....

 

[Birdstrike]

The problem with prescribing meds for bull**** is that it mis-educates the nurses/residents/patients that the patient actually needs something medical done.

Do you give tylenol or ibuprofen for fever?

 

[UKEMdoc]

Only if the patient's distressed by the fever.
Running a fever makes me feel rotten, I take some paracetamol(tylenol), the fever goes and I feel better. I know the evidence is equivocal at best but it's something I use myself.

When it comes to drugs like paracetamol, mallox and other things you can buy over the counter I quite often put them in PRN and let the nurses decide what to give.

 

[deleted109597]

That's fair enough, although I'm family practice. We spend a lot of time educating patients that if you're walking, talking, and thinking fairly normally, that rules out a LOT of acute life threatening conditions that they are convinced that they have.

This. If you're able to verbalize concern for the temp, then it isn't that bad FOR YOU. It might kill someone else, but they're altered by then, so the number doesn't bother them.

 

[thegenius]

They (RNs) do this **** all the time. Discharging a patient with uncomplicated diverticulitis: "No seeds, nuts, or popcorn." STOP! This is folklore... myth... legend.... stop.

But rustedfox, that poppy seed or cashew can get stuck in their diverticilitis! Then what do I do? Will it fall through my diverticulitis and just start floating around in me?

 

[thegenius]

Gotta be honest, I've seen plenty of people whose temp is <100.4 but still higher than normal, and they septic as duck. That cut-off of 100.4 seems arbitrary.

I think it has something to do with, back in the day, the lowest temp possible that correlated with septicemia. That is, the chance of having positive blood cultures below 100.4 is exceedingly rare.

I find this to be generally true in the normal healthy people < 70 age group (discounting chemo pts, AIDS, etc). I think in particular with young kids, who spike a fever if they breathe even a whiff an easterly wind.

 

[thegenius]

Do you give tylenol or ibuprofen for fever?

Most of the time yes because people don't feel good when they have a fever. But it does nothing for the primary endpoint, I agree.

 

[lymphocyte]

But it does nothing for the primary endpoint, I agree.

Unless you have a stroke or AMI. Fever jacks up VO2.

 

[GeneralVeers]

Fever is a normal biological process in children. It is NOT an illness or anything that needs to be addressed. Run-of-the-mill fever in children is just their underdeveloped immune system maturing as it encounters pathogens in the environment. I wish we could educate parents that this is not an emergency or even an urgency if their child is walking, talking, drinking and peeing.

 

[bravotwozero]

I discharged a kid home with fever, and hadn't treated him with antipyretics. Came back via ambulance 20 minutes later with a febrile seizure. I'll usually try to bring the fever down to minimize that from happening.

 

[deleted109597]

I think it has something to do with, back in the day, the lowest temp possible that correlated with septicemia. That is, the chance of having positive blood cultures below 100.4 is exceedingly rare.

Not.Even.Close.
Fevers are protective. That's why we still have them. Because our ancestors with fevers outlived those who didn't mount them.
See Fever Is Associated with Reduced, Hypothermia with Increased Mortality in Septic Patients: A Meta-Analysis of Clinical Trials

 

[Angry Birds]

I discharged a kid home with fever, and hadn't treated him with antipyretics. Came back via ambulance 20 minutes later with a febrile seizure. I'll usually try to bring the fever down to minimize that from happening.

I dunno, I was always taught that febrile seizure isn't prevented by controlling fever. Even so, I always treat fevers. Not only does it make people feel better, but also the optics aren't so good when your kid seizes 20 minutes after seeing them for fever.

Also, like I said, I love vital signs and love addressing them.

 

[hundreddaysoff]

The problem with prescribing meds for bull**** is that it mis-educates the nurses/residents/patients that the patient actually needs something medical done. This is the same reason I discharge URTIs with advice to buy something from a pharmacist.

I usually write scripts for OTC stuff for symptoms even if they're BS. Two reasons: (1) Gives the pt a compact artifact they can take to the pharmacist so they actually buy what I want them to buy in the right dose. (2) Seems to help my customer sat scores, at least in this area of the country where patients actually do what I tell them to do most of the time.

If there's nothing like Press-Ganey or another satisfaction torture device in the UK, then I agree it would just feed the bears and waste time.

 

[lymphocyte]

Not.Even.Close.
Fevers are protective. That's why we still have them. Because our ancestors with fevers outlived those who didn't mount them.
See Fever Is Associated with Reduced, Hypothermia with Increased Mortality in Septic Patients: A Meta-Analysis of Clinical Trials

This is the kind of paper I'd use with medical students to explain why correlation isn't necessarily causation. It's telling us that cold sepsis is bad, not "fevers are good." And it doesn't address antipyresis.

Another meta-analysis published in Critical Care last year actually showed improved early mortality in treating febrile septic patients (though equivocal 28-day mortality). And there's almost certainly a mortality benefit in stroke or AMI -- i.e. whenever vital tissue is under hypoxic threat.

I don't want to just "fix the numbers," but I do want to treat the patient in front of me. If they feel crummy, antipyretics will make them feel better. If I'm trying to minimise wasted VO2 in sick patients, antipyretics will help. If I discharge a febrile patient, I document why very, very clearly.

Drewry AM et al. Antipyretic therapy in critically ill septic patients: A systematic review and meta-analysis. Crit Care Med 2017 Feb 17