“and then I checked my blood pressure and…”

Panacea Financial Contract Review
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
I read an article about continuous glucose monitors being marketed to people without diabetes as a health monitoring device.

2 years from now it’ll be “my glucose monitor woke me up from sleep and…”
 
It’s always the pause for dramatic effect from the patient that gets me. Like im supposed to ready the cric tray and call the ICU.

This statement from a patient is essentially pathognomonic for not having emergent pathology, regardless of chief complaint.
 
Jabbed said:
I read an article about continuous glucose monitors being marketed to people without diabetes as a health monitoring device.

2 years from now it’ll be “my glucose monitor woke me up from sleep and…”
Click to expand...
Don’t forget “I think I have an infection from my glucose monitoring meter”
 
I print off the AHA/ACC guidelines on HTN and highlight the text in front of them.

https://www.ahajournals.org/doi/pdf/10.1161/HYP.0000000000000065
CleanShot 2024-06-21 at 12.41.32@2x.png
 
RustedFox said:
You print off all 103 pages of those guidelines and hand it to them?
Bravo, amigo.

View attachment 388317
Click to expand...
Maybe just the pertinent parts but definitely highlighting all the non-emergent sections. I've also sent it to referring doctors ...

Of course this usually gets the Press Ganey comment of "the doctor didn't seem to care about me"
 
I’m not sure if printing off these guidelines and giving them to these patients is a good use of anyone’s time. This is what I refer to as a lost encounter. Just discharge them and move on if you can’t convince them in a few minutes on why they don’t need anything done and actually need to throw their blood pressure machine away.
 
JacobMcCandles said:
I’m not sure if printing off these guidelines and giving them to these patients is a good use of anyone’s time. This is what I refer to as a lost encounter. Just discharge them and move on if you can’t convince them in a few minutes on why they don’t need anything done and actually need to throw their blood pressure machine away.
Click to expand...
Yeah, I just tell them that the current guidelines for high blood pressure in otherwise well patients is to do literally nothing and have them see their PCP. I usually smooth things over by saying something like "Yeah, high blood pressure absolutely increases your risk of stroke and heart attack, and it's definitely something you need to get under control, but it does that over months to years, not over hours/days/weeks. There's nothing to do about this today. You've got time. Call your pcp this week."
 
As a similar aside, I just discharged a woman a couple hours ago who refused to believe that her "tachycardia" (HR of 90, but she's normally in the 60s) might be due to the fact that the day before it started her PCP cut her metop in half. She was adamant that it couldn't happen that quickly. I really don't know, nor care, what some people want.
 
always.chillin said:
In my ER, admin is so obsessed about patient satisfaction that we are now expected to adjust people’s BP meds.
Click to expand...
Awesome, love when admin wants you to flirt with malpractice. That seems like an easy request to refuse, yes?
 
I've stopped arguing with these idiots...uh I mean customers. For people so obsessed with checking their BP and not on meds already I give them a 14 day supply of minimal dose Lisinopril and call it a day.
 
I'm a firm believer that BP cuffs should be prescription. Who wakes up at 2 am and just randomly checks their blood pressure? "Were you feeling bad when you checked it?" "No, I just woke up and checked it. It was high so I came to your ER to get checked."

"Thanks for the RVUs and job security. Let me get your discharge papers ready."
 
(insert age between 40-85 here) year old patient here today for high blood pressure. X patient woke up at 3am with sweats. Rushed to reach over to their nightstand and grabbed their wrist blood pressure cuff. Placed it over their bicep and cuff said ‘high’. Briskly paced to their vehicle and sped to the ER to check in. Triage BP: 160/92. X patient sees numbers, knew this visit was the right decision immediately. And ofcourse, there must be a wheelchair service to the treatment room, walking is not an option. Physician Y kindly explains the guidelines about why they can see their PCP. X Patient pays 200 dollar co-pay and requests refill on allergy meds while they’re here with some ice chips for the road. Discharge BP: 170/95. Patient tells their family, friends , pcp , Google reviews, and bingo group about their ER experience. The other simpletons gasp in horror at the entire situation, awestruck that patient X has lived to tell the tale without stroking out or worse, just 12 hours out from his ER visit. Shall the patient return back to the ER again in hopes a miracle shift change has occurred and another ER doctor may actually care? ‘Yes! Yes! You must!’ The simpletons yell. Stay tuned for the next episode of I’m burnt out.
 
Last edited:
I don't know what (if anything) they're teaching in middle school or high school health classes these days, but instead of showing photos of end-stage STDs for everyone to giggle at, they should be teaching some kind of "Your Body, How it Works, and How to Care for It." That and some basic personal finance would go a long way toward creating functional adults.
 
WhatJobDoIPick said:
I've stopped arguing with these idiots...uh I mean customers. For people so obsessed with checking their BP and not on meds already I give them a 14 day supply of minimal dose Lisinopril and call it a day.
Click to expand...
CCBs are preferred unless you're going to check a creatinine at the same time (note: I'm not saying you should be doing that).
 
People get aghast when I ask them if they've ever lifted anything heavy and tell them that their blood pressure might have gone into the 300s yet they shockingly lived through it all ...

pubmed.ncbi.nlm.nih.gov

Blood pressure changes during heavy-resistance exercise - PubMed

To study the mechanisms of the blood pressure changes during weight-lifting, three hypertensive and five normotensive body-builders underwent continuous intra-arterial monitoring. In two subjects (one normotensive and one hypertensive), intrathoracic and intra-abdominal pressures were also...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
southerndoc said:
I'm a firm believer that BP cuffs should be prescription. Who wakes up at 2 am and just randomly checks their blood pressure? "Were you feeling bad when you checked it?" "No, I just woke up and checked it. It was high so I came to your ER to get checked."

"Thanks for the RVUs and job security. Let me get your discharge papers ready."
Click to expand...

You can make these cases a 99285 so easily too:

-review prior records
-order labs
-independent interpretation of EKG
-high risk differential
-prescribe 5 mg lisinopril

Easy peasy
 
Brigade4Radiant said:
People demand their blood pressure to be lowered omg that doctor discharged you with a bp of 200 you were going to stroke out! It doesn't help when their family doctor sends them over there as well.
Click to expand...

Even better: 10 mg IV labetalol

For sure to get that 99285 and a great PG to boot
 
Tiger26 said:
People get aghast when I ask them if they've ever lifted anything heavy and tell them that their blood pressure might have gone into the 300s yet they shockingly lived through it all ...

pubmed.ncbi.nlm.nih.gov

Blood pressure changes during heavy-resistance exercise - PubMed

To study the mechanisms of the blood pressure changes during weight-lifting, three hypertensive and five normotensive body-builders underwent continuous intra-arterial monitoring. In two subjects (one normotensive and one hypertensive), intrathoracic and intra-abdominal pressures were also...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...

Don't explain physiology to people who already have their mind set on what they want. It's a great way to get a poor PG
 
Tiger26 said:
People get aghast when I ask them if they've ever lifted anything heavy and tell them that their blood pressure might have gone into the 300s yet they shockingly lived through it all ...

pubmed.ncbi.nlm.nih.gov

Blood pressure changes during heavy-resistance exercise - PubMed

To study the mechanisms of the blood pressure changes during weight-lifting, three hypertensive and five normotensive body-builders underwent continuous intra-arterial monitoring. In two subjects (one normotensive and one hypertensive), intrathoracic and intra-abdominal pressures were also...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...

GymBro here. I say this to patients all the time, too.
 
WhatJobDoIPick said:
Even better: 10 mg IV labetalol

For sure to get that 99285 and a great PG to boot
Click to expand...
And then you're going to get them coming back again and again unnecessarily. Just like patients who say "my PCP always gives me a z-pack and prednisone" for this. I'd prefer appropriate medical management and an attempt at education over a Level 5 chart.
 
I've fought this battle so many times not just with patients and their family members, but also with nurses and hospitalists. Is someone teaching that normotensive people wake up one day with elevated blood pressure that rapidly climbs and if not treated aggressively they "stroke out?"

A few months ago I admitted a 20yo otherwise healthy patient for appy. I happened to glance at the FM resident's admitting orders and noted prn orders for hypertension. Why????
 
JacobMcCandles said:
And then you're going to get them coming back again and again unnecessarily. Just like patients who say "my PCP always gives me a z-pack and prednisone" for this. I'd prefer appropriate medical management and an attempt at education over a Level 5 chart.
Click to expand...
This is my biggest hang up with the “treat and discharge”, is that they’ll inevitably be back 2-3 more times that week if you don’t educate them.

That, and I’ve seen patients come back hypotensive when ER docs have adjusted BP meds off one visit (though I make exception for starting 5mg amlodipine for someone with an obvious trend of high BP. That’s not gonna hurt anyone in the PCP follow-up window. Still rarely do it though.)
 
Ceez said:
I've fought this battle so many times not just with patients and their family members, but also with nurses and hospitalists. Is someone teaching that normotensive people wake up one day with elevated blood pressure that rapidly climbs and if not treated aggressively they "stroke out?"

A few months ago I admitted a 20yo otherwise healthy patient for appy. I happened to glance at the FM resident's admitting orders and noted prn orders for hypertension. Why????
Click to expand...
Yes. Here is the MAYO CLINIC telling people to call 911 for high blood pressures. No mention of symptoms. This is what we are up against in the knowledge war.

www.mayoclinic.org

High blood pressure (hypertension): Controlling this common health problem-High blood pressure (hypertension) - Symptoms & causes - Mayo Clinic

Learn the symptoms and treatment of this condition — which raises the risk of heart attack and stroke — and the lifestyle changes that can lower the risk.
www.mayoclinic.org www.mayoclinic.org
 
I've seen this so many times, but I always ask about the symptoms. Sometimes you might catch something.

On a separate note, the best one liners I use (and they work really well)...

"We were NEVER meant to check our blood pressures regularly, if you think back 20 years ago, you saw your doctor once a year for your annual checkup. If on that date you had high blood pressure, they would say "lets recheck it in 6 months, or next year". That was it. One BP check, once a year, done. We NEVER were meant to be checking our BP 16 times a day".

or "I'll say, our BP is very dynamic and we know this because we use arterial lines in sick patients. If we look at real time measurements, they will fluctuate from the 80's when we're asleep, to 180 when we are stressed, all in the matter of minutes. We were NEVER meant to take BP measurements hourly on normal people".

That usually will reassure them enough.
 
WhatJobDoIPick said:
You keep saying this, and others keep saying they know people with these jobs. I guess we're lying.
Click to expand...

skougess said:
This is my biggest hang up with the “treat and discharge”, is that they’ll inevitably be back 2-3 more times that week if you don’t educate them.

That, and I’ve seen patients come back hypotensive when ER docs have adjusted BP meds off one visit (though I make exception for starting 5mg amlodipine for someone with an obvious trend of high BP. That’s not gonna hurt anyone in the PCP follow-up window. Still rarely do it though.)
Click to expand...
They’ll get the hint quicker that they don’t need to be in the ED when nothing is done. If unnecessary interventions happen then they’ll see that as positive reinforcement that they need to be there.

With that said, there’s definitely an art to this. Playing the “I’m doing something” game is different at a busy ED than a slower one.
 
skougess said:
This is my biggest hang up with the “treat and discharge”, is that they’ll inevitably be back 2-3 more times that week if you don’t educate them.

That, and I’ve seen patients come back hypotensive when ER docs have adjusted BP meds off one visit (though I make exception for starting 5mg amlodipine for someone with an obvious trend of high BP. That’s not gonna hurt anyone in the PCP follow-up window. Still rarely do it though.)
Click to expand...
JacobMcCandles said:
And then you're going to get them coming back again and again unnecessarily. Just like patients who say "my PCP always gives me a z-pack and prednisone" for this. I'd prefer appropriate medical management and an attempt at education over a Level 5 chart.
Click to expand...

That's nice. I'll take the 99285 and top box PG every time. I give patients the option to start 5mg Lisinopril vs wait to see their PCP and they can decide. We're so adverse sometimes to doing things within our scope of practice. Starting low dose SSRI in an appropriate patient is another one. If there's no substance abuse concerns and I've screened for mania, I have no issue starting 5 mg Lexapro in the ED. Sometimes it's ok to do non-emergent management in the ED.
 
WhatJobDoIPick said:
That's nice. I'll take the 99285 and top box PG every time. I give patients the option to start 5mg Lisinopril vs wait to see their PCP and they can decide. We're so adverse sometimes to doing things within our scope of practice. Starting low dose SSRI in an appropriate patient is another one. If there's no substance abuse concerns and I've screened for mania, I have no issue starting 5 mg Lexapro in the ED. Sometimes it's ok to do non-emergent management in the ED.
Click to expand...
I’ll take appropriate medicine over unnecessary up-billing and flawed surveys. With that said, I have no problems starting people on anti-hypertensives, metformin, etc. but I’d prefer someone have close follow-up for depression before I start on antidepressants. I think those are overall not a great class of medicines. And, if they have close follow up then they can have their PCP prescribe it.
 
skougess said:
Awesome, love when admin wants you to flirt with malpractice. That seems like an easy request to refuse, yes?
Click to expand...
Not really. I refused once and I got a patient complaint and was told to do it. So now I spend maybe a minute with patients like this and just increase their dose or start them on amlodipine. I don’t work there much anymore because of entitled ****s but this particular place would immediately draw labs and EKG on any patient coming in with elevated BP as their chief complaint.
 
JacobMcCandles said:
I’ll take appropriate medicine over unnecessary up-billing and flawed surveys. With that said, I have no problems starting people on anti-hypertensives, metformin, etc. but I’d prefer someone have close follow-up for depression before I start on antidepressants. I think those are overall not a great class of medicines. And, if they have close follow up then they can have their PCP prescribe it.
Click to expand...

How's it unnecessary? You're checking a Cr and an EKG which no one would ever bat an eye at for a person with systolic 180. It's what their PCP would do. I considered "hypertensive emergency" and ruled it out. The patient elected to have this evaluation done in the ED rather than by their PCP, that's their issue, and I'm going to be properly paid for my efforts.
 
WhatJobDoIPick said:
How's it unnecessary? You're checking a Cr and an EKG which no one would ever bat an eye at for a person with systolic 180. It's what their PCP would do. I considered "hypertensive emergency" and ruled it out. The patient elected to have this evaluation done in the ED rather than by their PCP, that's their issue, and I'm going to be properly paid for my efforts.
Click to expand...
I don’t think we need to reinvent the wheel on asymptomatic hypertension. This is well established standard of care now. Testing “just because” hurts patients.
 
skougess said:
I don’t think we need to reinvent the wheel on asymptomatic hypertension. This is well established standard of care now. Testing “just because” hurts patients.
Click to expand...
How does it hurt them? No one's saying to check a troponin.

Their PCP is for sure checking a creatinine and an EKG
 
WhatJobDoIPick said:
How does it hurt them? No one's saying to check a troponin.

Their PCP is for sure checking a creatinine and an EKG
Click to expand...
The same way all unnecessary testing has the potential to cause harm. Cmon, don’t make Tiger have to print out the guidelines for you.

Any PCP checking an EKG for asymptomatic htn is practicing poor medicine. They probably check Cr for initiation of anti hypertensives.
 
Last edited:
WhatJobDoIPick said:
That's nice. I'll take the 99285 and top box PG every time. I give patients the option to start 5mg Lisinopril vs wait to see their PCP and they can decide. We're so adverse sometimes to doing things within our scope of practice. Starting low dose SSRI in an appropriate patient is another one. If there's no substance abuse concerns and I've screened for mania, I have no issue starting 5 mg Lexapro in the ED. Sometimes it's ok to do non-emergent management in the ED.
Click to expand...
I realize you can get sued for anything at anytime. But dabbling in primary care as an ER physician is just playing Russian roulette. Starting an SSRI is easy but not part of our training. How are you going to defend yourself when a patient commits suicide 3 days after initiation of an SSRI and the prosecution asks you if you were aware that certain SSRIs can increase suicidality in the first few weeks and what was your plan to monitor this patient? Oh and here are 99% of ER physicians as expert witnesses saying they would never start an SSRI in the ER setting.

Things can get away from you quickly in the courtroom if you don’t stay in your lane in the ER.
 
WhatJobDoIPick said:
How's it unnecessary? You're checking a Cr and an EKG which no one would ever bat an eye at for a person with systolic 180. It's what their PCP would do. I considered "hypertensive emergency" and ruled it out. The patient elected to have this evaluation done in the ED rather than by their PCP, that's their issue, and I'm going to be properly paid for my efforts.
Click to expand...
It’s pretty cut and dry, especially when there’s clinical guidelines on asymptomatic hypertension that say nothing emergent needs to be done except counseling.

It’s interesting you say ‘properly paid’ because you’ll still get reimbursed “properly” for asymptomatic hypertension and doing appropriate care (counseling) but you’re making the medical complexity unnecessarily higher.
 
skougess said:
I realize you can get sued for anything at anytime. But dabbling in primary care as an ER physician is just playing Russian roulette. Starting an SSRI is easy but not part of our training. How are you going to defend yourself when a patient commits suicide 3 days after initiation of an SSRI and the prosecution asks you if you were aware that certain SSRIs can increase suicidality in the first few weeks and what was your plan to monitor this patient? Oh and here are 99% of ER physicians as expert witnesses saying they would never start an SSRI in the ER setting.

Things can get away from you quickly in the courtroom if you don’t stay in your lane in the ER.
Click to expand...

Please. Patient with generalized anxiety with no mania risk factors there is literally close to zero risk starting 5 mg Lexapro and following up with PCP. Patients come to us with problems, it's ok to be a doctor and help them out while they're waiting 2 weeks for a PCP appointment.

We let NPs fresh out of online school sling max dose SSRI but a board certified EP starting baby dose Lexapro is what we have an issue with.
 
skougess said:
The same way all unnecessary testing has the potential to cause harm. Cmon, don’t make Tiger have to print out the guidelines for you.

Any PCP checking an EKG for asymptomatic htn is practicing poor medicine. They probably check Cr for initiation of anti hypertensives.
Click to expand...

Do you get an EKG for hip fracture? Why?

Do you treat otitis media and streptococcal pharyngitis with antibiotics? Why?

Do you check a Cr before giving IV contrast? Why?

Lots of things we do in medicine are "just cause" and have little basis in evidence.
 
WhatJobDoIPick said:
Please. Patient with generalized anxiety with no mania risk factors there is literally close to zero risk starting 5 mg Lexapro and following up with PCP. Patients come to us with problems, it's ok to be a doctor and help them out while they're waiting 2 weeks for a PCP appointment.

We let NPs fresh out of online school sling max dose SSRI but a board certified EP starting baby dose Lexapro is what we have an issue with.
Click to expand...
I'd rather you didn't, but I won't make a fuss if you do.
 
WhatJobDoIPick said:
Please. Patient with generalized anxiety with no mania risk factors there is literally close to zero risk starting 5 mg Lexapro and following up with PCP. Patients come to us with problems, it's ok to be a doctor and help them out while they're waiting 2 weeks for a PCP appointment.

We let NPs fresh out of online school sling max dose SSRI but a board certified EP starting baby dose Lexapro is what we have an issue with.
Click to expand...
Hey I think I was not clear before, which is my bad. I’m not suggesting at all that an ER doc shouldn’t be able to start an SSRI in clear cut cases if they are up to date on the basics of which ones for which types of patients. You’re probably doing a service to your patients.

What I’m saying is that when there is a 1/1000 random bad outcome (that your initiation of SSRI certainly didn’t cause), you better get out your check book because you will have no defense. Med mal isn’t about what is good or bad medicine. It’s about bad outcomes and standard of care. You will NOT successfully argue that ER docs starting an SSRI is standard of care to a judge. It’s unfortunate but it is what it is.
 
skougess said:
Hey I think I was not clear before, which is my bad. I’m not suggesting at all that an ER doc shouldn’t be able to start an SSRI in clear cut cases if they are up to date on the basics of which ones for which types of patients. You’re probably doing a service to your patients.

What I’m saying is that when there is a 1/1000 random bad outcome (that your initiation of SSRI certainly didn’t cause), you better get out your check book because you will have no defense. Med mal isn’t about what is good or bad medicine. It’s about bad outcomes and standard of care. You will NOT successfully argue that ER docs starting an SSRI is standard of care to a judge. It’s unfortunate but it is what it is.
Click to expand...

Fair enough. I'll take that 1/1000 chance. We take a lot worse chances every day at work. I disagree that there's no defense though. If NPs can do it, certainly a board certified generalist can.
 
You must log in or register to reply here.

Similar threads

Angry Birds
I like treat and street patients
2 3
Replies
131
Views
9K
Mount Asclepius
Mount Asclepius
CajunMedic
And so the expansion continues...
Replies
14
Views
2K
xaelia
xaelia
RustedFox
Of Dimers and DVTs
Replies
28
Views
2K
RustedFox
RustedFox
F
I want to leave EM and open a ketamine/wellness clinic
2 3
Replies
134
Views
8K
Apollyon
A
Dr. Ditka
Staff Checked Off to Translate
Replies
1
Views
1K
gutonc
gutonc
Top