A frustrating situation in a distant ER

[UTSouthwestern]

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A question regarding a situation I encountered yesterday and today:

In an ER in another city, my friend was seen for a very nonspecific "ill" feeling along with a BP of 210/104. He is an end stage renal patient on dialysis, secondary to chronic hypertension. Over the past 7 years on dialysis, he has been very regimented and strict with his diet, exercise, and medications. He is 70 years old, but otherwise a very active individual.

His BP runs normally in the 120-140 range systolic, usually toward 140 only when he has just done something with great physical exertion.

He was seen quickly in the ER, told the ER physician that he did not feel well, but could not pin down a specific complaint (headache, chest pain, etc.), only a "feeling" that he was not well. Upon seeing his BP, he was given clonidine (PO). When an IV was placed, "the blood was shooting out of the IV across the floor at least two feet away," according to his daughter. At the next reading, his BP was 202/100 and he was quickly discharged with a prescription for oral clonidine.

I was called by his daughter about four hours later when his home BP device registered 220/113 despite his having taken at least three of the clonidine tabs. I told her to immediately take him back to the hospital at which time, another ER physician at the same hospital told them that he was OK and just needed to let the medication work. Just prior to him being discharged again, the BP cuff registered 232/118, at which time the daughter called me again and I then spoke with the ER physician, asking why this type of hypertensive urgency wasn't enough to convince him to at least contact my friend's internist or nephrologist.

Am I missing something? Is this type of pressure not considered serious enough to admit a 70 year old dialysis patient that has a record of normal to high normal BP over the past 7 years?

Just venting as I have had the first bad experience I have ever had with an ER physician.

 

[bartleby]

This is surprisingly good blood pressure for someone with end-stage renal disease due to long-term uncontrolled hypertension..

He is an end stage renal patient on dialysis, secondary to chronic hypertension...His BP runs normally in the 120-140 range systolic, usually toward 140 only when he has just done something with great physical exertion.

Unless an IV is inadvertently placed arterially, this does not happen.

When an IV was placed, "the blood was shooting out of the IV across the floor at least two feet away,".

With good followup (which a patient on hemodialysis dialysis has by definition) and a treatment plan, this patient with hypertensive urgency, (no evidence of end-organ damage: no chest pain/chf, headache/stroke sx, or evidence of renal failure in the non-hemodialysis patient) has no compelling reason to admit the patient. While satisfying to the physician, immediately restoring their BP to baseline (pharmacologically, by means of IV meds) is actually the worst thing you can do for them, as you can acutally precipitate cerebral ischemia and interfere with cerebral autoregulation.

There is nothing wrong with keeping the patient's nephrologist in the loop, but they typically try to avoid admission except in cases of hyperkalemia, CHF due to volume overload, etc. Based on your question, it does not appear that the nephrologist urgently admitted the patient to the ICU. Despite your friend's good fortune so far, dialysis patients are ill at baseline, and this is even more the case in the setting of elderly patients.

 

[UTSouthwestern]

There is nothing wrong with keeping the patient's nephrologist in the loop, but they typically try to avoid admission except in cases of hyperkalemia, CHF due to volume overload, etc. Based on your question, it does not appear that the nephrologist urgently admitted the patient to the ICU. Despite your friend's good fortune so far, dialysis patients are ill at baseline, and this is even more the case in the setting of elderly patients.

What I should make clear on the last point is that the ER physicians did not and would not notify the nephrologist despite my and my friend's daughter's requests. My friend's daughter called the answering service and left a message for him which he apparently just received about 15 minutes ago. He is admitting him and told the daughter that given her father's usual blood pressure range, this large increase over the past day was something that had to be immediately treated.

Regarding the IV, it was not an arterial stick as they are using it to administer meds. They did put the IV in the same arm as his dialysis shunt, so I am praying they did not inadvertently cannulate the shunt.

I agree with you that if his pressures were chronically elevated that immediate lowering of his pressure into a normal range would risk end organ ischemia. However, for the past seven years, his pressure has been in the normal range and the readings over the past 24 hours represented a 50-70% increase over his baseline. Prior to that, his hypertension hovered around the 150's-160's systolic.

Unfortunately, my friend's daughter has told me that he began experiencing chest pains about 30 minutes ago and in addition to the nephrologist's involvement, a cardiologist has been notified and has agreed with the admission plan to PCU (one step below ICU at this facility). His BP remains in the 220-230 range systolic over 110-120 diastolic with HR's in the 70's-90's.

 

[waterski232002]

Agree... it is extremely rare for an ESRD pt on dialysis to have BP well controlled at 120 (unless the pt had CHF as well). It would be rare to have their BP controlled at 160! The fluctuance in volume between dialysis makes their BP extremely hard to control and swings into the 200 range are not uncommon when it's at the tail of a 48 hr interval between dialysis treatments.

The important thing is to check for end organ damage as bartleby stated... r/o stroke, MI, CHF, uremia, hyperkalemia, or other electrolyte abnormality. If these are not present, the BP alone is not a reason for admission. If he had a crushing headache, visual changes, or chest pain than certainly the EM physician would have been more aggressive about treating the BP, but it doesn't sound like that was the case. So conservative management is the safest and best, which sounds like the action which was taken.

 

[Apollyon]

As we don't know the underlying cause of the ESRD, I can't be sure, but...

If diabetes was the origin, the patient could be having a silent MI, and I would be looking for end-organ damage by cardiac markers, and, as that is an issue with ESRD patients, the nephrologist gets a call. I'm conservative, but, a general-ill ESRD patient at least gets a call to the nephrologist. One key is the self-selection - chronically ill patients (that are not crazy) know when they're worse off than normal - that already gets them a heads up on my radar.

One thing, though - I wonder if these docs in this 'distant ER' were EM-trained.

 

[UTSouthwestern]

Agree... it is extremely rare for an ESRD pt on dialysis to have BP well controlled at 120 (unless the pt had CHF as well). It would be rare to have their BP controlled at 160! The fluctuance in volume between dialysis makes their BP extremely hard to control and swings into the 200 range are not uncommon when it's at the tail of a 48 hr interval between dialysis treatments.

The important thing is to check for end organ damage as bartleby stated... r/o stroke, MI, CHF, uremia, hyperkalemia, or other electrolyte abnormality. If these are not present, the BP alone is not a reason for admission. If he had a crushing headache, visual changes, or chest pain than certainly the EM physician would have been more aggressive about treating the BP, but it doesn't sound like that was the case. So conservative management is the safest and best, which sounds like the action which was taken.

The BP issues began approximately 8 hours after his last dialysis run on Friday.

While I can understand conservative treatment in light of non-specific symptoms, at what point would you aggressively treat especially in light of such high pressures. I understand that ESRD patients typically live at higher pressures, especially at the end of the dialysis interval, but with my friend being so strict in his control such that his BP journal shows consistently normal - high normal pressures, would you treat this type of patient with such a highly abnormal pressure variance, in spite of the lack of glaring symptoms? Unfortunately, it seems like he has moved past this gray area into a more clearly pathologic state.

I am not sure if these ER physicians are EM trained, but it is in a large state capital, albeit in a smaller community hospital. I will try to find out tomorrow.

 

[Apollyon]

I need to clarify "conservative" - in my statement, I meant I'm more likely to overtreat than undertreat; i.e., I would tend to keep this patient more than to discharge them.

 

[waterski232002]

I guess there was a gross misunderstanding from the get-go. If a patient says the magic words of "headache" or "chest pain" at ANY time during the H+P to an EP, that triggers a multitude of follow up questions.... so based on the initial account, I'm guessing that the patient said "no" to those inquiries. Even if a patient says "ummmm.... not pains, but uncomfortable in my chest" that sets off a BIG RED ALARM in any EP's mind (or it should, anyways).

And about the nephrologist or cardiologist who supposidly talked to the patient, and assured admission.... This is one of the things that drives me MOST crazy. If the nephrologist or cardiologist felt that strongly about admitting the patient, then surely he would call the ED and place an expect note, instructing the ED to admit the patient. Do you realize how often patients come to the ED saying "my doc told me I would be admitted" or "my doc told me he would meet me here".🙄 Usually this is what the PMD says to their patient as a dump on the ED and we have to deal with the consequences. If they truly believed that, then there would be an expect note.

I'm not saying that the nephrologist/cardiologist didn't say it... just saying that it has as much credibility as the girl who gave me a lap dance last night.😉 And if the patient began experiencing chest pains AFTER he left the ER, than that is clearly a different story, and has no bearing on the previous visit. I am quite sure that he was instructed upon discharge to return if he experiences any chest pain, shortness of breath, headache, or visual changes. You can't expect the EP to predict the future... but educating and informing the patient is key.

Lastly... I guess there is also a mistake on the patients baseline BP. Originally you said it was 120's (140's only with great physical exertion), now it seems like 160's was baseline. So I don't think it was so clear cut, even in your friends mind.

 

[SoCuteMD]

I agree with you that if his pressures were chronically elevated that immediate lowering of his pressure into a normal range would risk end organ ischemia. However, for the past seven years, his pressure has been in the normal range and the readings over the past 24 hours represented a 50-70% increase over his baseline. Prior to that, his hypertension hovered around the 150's-160's systolic.

I"m not arguing that 210-220 isn't a huge increase, but 150-160 is most definitely NOT "normal range."

 

[southerndoc]

It's very rare for any of our private patients to be seen and not have the PMD contacted, regardless how simple it is. We have a good mix of clinic and private patients. When I suture up a laceration of a private patient, guess what? I contact the PMD. It's the policy of our ED.

So if someone comes in with severe hypertension, the PMD (and in this case, the neprhologist) would be contacted. In the case of this patient, it would be before the patient was discharged to see if the nephrologist had any additional recommendations.

Cannulating an IV in an arm with a shunt/AV fistula is a bad idea, and I'm surprised they actually did it. It is possible for blood to "shoot two feet" from a venous cannulation in an arm that has a shunt. This wouldn't happen on a non-shunted extremity though.

I see patients all the time with extreme blood pressures. Usually they get discharged if there isn't any sign of end-organ damage. However, I rarely -- if ever -- discharge a patient without their blood pressure at least trending down. If the blood pressure continues to increase, then I rethink the strategy of outpatient management.

 

[UTSouthwestern]

I"m not arguing that 210-220 isn't a huge increase, but 150-160 is most definitely NOT "normal range."

For clarification:

His pressures normally run in the 120's - 140's in the past seven years.

PRIOR to these past seven years (i.e., when he was unaware of his hypertension and was heading on the road to renal failure and dialysis), his pressures ran 150's - 160's.

 

[bulgethetwine]

I"m not arguing that 210-220 isn't a huge increase, but 150-160 is most definitely NOT "normal range."

Agree that 150-160 is not normal range... (but I have an anxiety building hoping that this thread won't rehash 'normal range' and go into the whole Pandora's Box of how 120 SBP is based on population means blah blah blah).

BUT

In an asymptomatic dialysis patient, 150-160 is not something I would act on. So in this sense, it is normal range (in colloquial terms) 😳

 

[UTSouthwestern]

I guess there was a gross misunderstanding from the get-go. If a patient says the magic words of "headache" or "chest pain" at ANY time during the H+P to an EP, that triggers a multitude of follow up questions.... so based on the initial account, I'm guessing that the patient said "no" to those inquiries. Even if a patient says "ummmm.... not pains, but uncomfortable in my chest" that sets off a BIG RED ALARM in any EP's mind (or it should, anyways).

And about the nephrologist or cardiologist who supposidly talked to the patient, and assured admission.... This is one of the things that drives me MOST crazy. If the nephrologist or cardiologist felt that strongly about admitting the patient, then surely he would call the ED and place an expect note, instructing the ED to admit the patient. Do you realize how often patients come to the ED saying "my doc told me I would be admitted" or "my doc told me he would meet me here".🙄 Usually this is what the PMD says to their patient as a dump on the ED and we have to deal with the consequences. If they truly believed that, then there would be an expect note.

I'm not saying that the nephrologist/cardiologist didn't say it... just saying that it has as much credibility as the girl who gave me a lap dance last night.😉 And if the patient began experiencing chest pains AFTER he left the ER, than that is clearly a different story, and has no bearing on the previous visit. I am quite sure that he was instructed upon discharge to return if he experiences any chest pain, shortness of breath, headache, or visual changes. You can't expect the EP to predict the future... but educating and informing the patient is key.

Reread my post. The nephrologist was never notified by the first doc, prior to his being discharged the first time. When his pressure remained high, I asked him to go back to the ER and that is when he saw saw the second ER physician. At that time, his daughter then called the nephrologist and left a message with the answering service, to which the nephrologist responded to and ultimately admitted him to the hospital. The nephrologist then brought the cardiologist on board to evaluate his cardiac status.

In no way was the nephrologist "dumping" on the ER because he wasn't even notified until the middle of the second visit, and even then, it was by the patient's daughter, not the ER physician. If anything, the nephrologist removed the patient from the ER, not dumped him there.

As a final note, my friend's shunt clotted at some point yesterday and he did have elevated cardiac enzymes, although the significance of the latter is still being evaluated. The important thing is that his pressure this AM is 139/64 with a normal heart rate, and he just "feels" better subjectively.

 

[waterski232002]

Reread my post. The nephrologist was never notified by the first doc, prior to his being discharged the first time. When his pressure remained high, I asked him to go back to the ER and that is when he saw saw the second ER physician. At that time, his daughter then called the nephrologist and left a message with the answering service, to which the nephrologist responded to and ultimately admitted him to the hospital. The nephrologist then brought the cardiologist on board to evaluate his cardiac status.

In no way was the nephrologist "dumping" on the ER because he wasn't even notified until the middle of the second visit, and even then, it was by the patient's daughter, not the ER physician. If anything, the nephrologist removed the patient from the ER, not dumped him there.

As a final note, my friend's shunt clotted at some point yesterday and he did have elevated cardiac enzymes, although the significance of the latter is still being evaluated. The important thing is that his pressure this AM is 139/64 with a normal heart rate, and he just "feels" better subjectively.

I gotcha now... the time course wasn't clear from your earlier post. In any event, the situation sounds like it must have been very frustrating for both you and your friend. I agree, it would have been a good idea for the EM doc to call the PMD/nephrologist and let them know about the situation (especially if it was during the day). The PMD's advice is usually very helpful as they know the patient best.

Either way, a return visit with chest pain is virtually a slam dunk admit. I hope everything goes alright.

 

[Jeff698]

The key factor for me if I were seeing this patient is that he is:

1) old
2) chronically, seriously sick
3) on dialysis
4) doesn't "feel right".

Even with only vague complaints, I'm going to have a very high index of suspicion for badness. I typically cast a pretty wide net for these patients. I assume that they can't give me a good story. Chronic disease and age deprive one of the ability to pinpoint disease as easily as when they were younger and healthier.

One of my attendings likes to say "the organs of the elderly cry softly", meaning that the elderly are often only mildly symptomatic even when very sick.

While I can't imagine how slowly my throughput would be if, like Southerdoc, I called every patient's PCP, I do contact the nephrologist of the dialysis patients I see. At least at our place, the nephrologist know each and every one of their patients with a degree of familiarity that I find amazing. Unlike their medicine colleagues, they actually want to be contacted.

Finally, it isn't clear to me that the basis for your friends 'ill' feeling was his elevated blood pressure. He could have some other underlying condition going on that both makes him feel 'ill' and elevates his pressure. As a result, simply lowering his pressure could very well be missing the real problem.

Take care,
Jeff

 

[UTSouthwestern]

Finally, it isn't clear to me that the basis for your friends 'ill' feeling was his elevated blood pressure. He could have some other underlying condition going on that both makes him feel 'ill' and elevates his pressure. As a result, simply lowering his pressure could very well be missing the real problem.

Take care,
Jeff

I completely agree. Hence my frustration with his quick discharge. Not only did they not search for an underlying cause (including examining the shunt for closure/clot), they didn't even successfully lower the pressure or trend it down. He has always been a little unsteady with his chronically arthritic hips, knees, and back problems. Can't imagine how bad it would have been if he had fallen at that time with his pressures at those levels, especially if he bumped his head.

With his age, his comorbidities, and his presentation, like you, I would have had a much higher index of suspicion and would have at the very least, contacted his PCP or his nephrologist. Ironically, I found out that his first ER doc was an intern on one of my MICU teams when I was a medicine resident. He and the second ER physician are EM certified to answer a previous question on this thread.

As it turns out, he did have a mild anteroseptal MI, but the cardiologist isn't sure it was the cause of his BP or a result of his BP elevation. The shunt was declotted yesterday by interventional radiology and is functional and his BP issues have apparently resolved as has his subjective ill feeling.