Things I hate to hear patients say:

[Birdstrike]

I had a septic patient refuse antibiotics until we find out if there's gluten in it

I completely ignored the request for obvious reasons

but then the nurse starts freaking out and gets upset because she might be giving gluten to a gluten-allergic patient

out of overwhelming boredom I ask the pharmacist if it has gluten in it

apparently it did, and so does a few other antibiotics we carry

I don't remember which antibiotics it was because I still don't care, but apparently gluten-free antibiotics is a thing

Hmm...Interesting. Found this:

Gluten content of medications:
Gluten content of medications. - PubMed - NCBI

Just another thing for patients to freak out about, I guess.

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[WilcoWorld]

I had a septic patient refuse antibiotics until we find out if there's gluten in it

I completely ignored the request for obvious reasons

but then the nurse starts freaking out and gets upset because she might be giving gluten to a gluten-allergic patient

out of overwhelming boredom I ask the pharmacist if it has gluten in it

apparently it did, and so does a few other antibiotics we carry

I don't remember which antibiotics it was because I still don't care, but apparently gluten-free antibiotics is a thing

Hmm...Interesting. Found this:

Gluten content of medications:.
Gluten content of medications. - PubMed - NCBI.

Just another thing for patients to freak out about, I guess..

I think I'm more allergic to gram negative endotoxins.

 

[Birdstrike]

I think I'm more allergic to gram negative endotoxins.

Your allergy list is 37 allergies long. You're a unique & rare flower.

 

[deleted859535]

Your allergy list is 37 allergies long. You're a unique & rare flower.

Also allergic to flowers.

 

[ThoracicGuy]

But essential oils probably would have helped.

Coconut Oil.

 

[dchristismi]

Coconut Oil.

No. It's the rum that helps. Lots of rum.

 

[deleted804295]

"I try to use all-natural solutions if I can."

"My Nurse Practitioner knows more because she considers the 'whole patient' ."

"I like to do things holistically." [Bonus if I ask them what the word "holistic" means and they can't form an answer.]

"I've done my research."

"Vaccines are just a scheme for big pharma to make money."

"I didn't know what to do, so I took my blood pressure, and..."

Following the last one:
"My blood pressure was high and I don't want to have a stroke; so I came in right away."

"My doctor said that [xxx: generally another physician] would meet me here to take care of me."

"I threw my kid right in the car and drove here as fast as I could!" [Good job, SuperMom! Way to endanger motorists and pedestrians everywhere for that 99.4 fever!]

"How long is this going to take?! I have my doctor's appointment at [xxx], you know."

"I didn't want to take [tylenol/motrin/etc] because I didn't want to "mask the symptoms"."

"I didn't want my organs to just start shutting down; so I came in right away." [Zero ****!ng idea what they mean when they say this.]

"I'm going on a long trip, so I wanted to come in to make sure that I'd be okay on the trip."


Take it away, SDN.

Wait... I was redirected here by Goro' thread btw... But why is refusing to take pain killers so that you don't disguise symptoms a bad thing?

I skip pain killers sometimes during my cycle if I feel like I'm getting TSS symptoms

 

[GeneralVeers]

Wait... I was redirected here by Goro' thread btw... But why is refusing to take pain killers so that you don't disguise symptoms a bad thing?

I skip pain killers sometimes during my cycle if I feel like I'm getting TSS symptoms

Just don't ask me for pain medication if you have not even taken a Motrin at home.

 

[deleted804295]

Just don't ask me for pain medication if you have not even taken a Motrin at home.

Oh. You're worried for patients who want pain meds that haven't tried over the counter stuff.

I thought you guys were worried about people not using pain meds so that symptoms would not be disguised.

 

[InternistDO]

Wait... I was redirected here by Goro' thread btw... But why is refusing to take pain killers so that you don't disguise symptoms a bad thing?

I skip pain killers sometimes during my cycle if I feel like I'm getting TSS symptoms

Not "masking" pain with painkillers used to be an actual recommendation, in the days where physical exams were much more critical, before easy access to imaging and labs. These days with CTs/MRIs/Ultrasound etc there's no need to hold back on pain medicine for the purpose of messing up the exam.

I guess there's nothing "wrong" with it, but you're needlessly putting yourself through pain.

 

[RustedFox]

Wait... I was redirected here by Goro' thread btw... But why is refusing to take pain killers so that you don't disguise symptoms a bad thing?

I skip pain killers sometimes during my cycle if I feel like I'm getting TSS symptoms

What thread?

 

[Ms Procrastinator]

No. It's the rum that helps. Lots of rum.

You guys would probably looooove my dad. He'd probably be dragged into the ER with a bullet to the head and refuse meds saying that herbal tea would fix it. Seriously, it fixes everything. As a kid I quickly learned to not to tell him when I had things like headaches and to hide and take pain killers when I take them (or else he'd force me to drink his crap teas).
Edit: He'd probably dress the wound with rum, no joke.

 

[VA Hopeful Dr]

Not "masking" pain with painkillers used to be an actual recommendation, in the days where physical exams were much more critical, before easy access to imaging and labs. These days with CTs/MRIs/Ultrasound etc there's no need to hold back on pain medicine for the purpose of messing up the exam.

I guess there's nothing "wrong" with it, but you're needlessly putting yourself through pain.

Its like parents not giving kids tylenol "So you can see that they have a fever".

If you have a thermometer and tell me it read 102 at home, I'll believe you.

If you don't have a thermometer, I'm going to fuss at you for not having one. Its $5 at CVS and you have a freaking kid.

 

[deleted938090]

I've encountered someone who didn't take pain medications because they "can take pain like a man".

 

[BJJVP]

But why is refusing to take pain killers so that you don't disguise symptoms a bad thing?

Refusing to take the pain medications is perfectly fine. The problem is that in patients who say such things, the pain is often some vague, chronic, non-debilitating pain, which has been worked up extensively prior to their ER visit.

 

[smq123]

Refusing to take the pain medications is perfectly fine. The problem is that in patients who say such things, the pain is often some vague, chronic, non-debilitating pain, which has been worked up extensively prior to their ER visit.

"My PCP, rheumatologist, neurologist, orthopedist, and pain management specialists don't know what is causing my pain, so I came to the ER to get some answers!"

 

[BoardingDoc]

"My PCP, rheumatologist, neurologist, orthopedist, and pain management specialists don't know what is causing my pain, so I came to the ER to get some answers!"

Just had someone come in for a rash because it wasn't getting better after being treated by two different dermatologists. The first thing I said was "before I examine you, you should know that there is a near zero chance that I'm going to be able to do better than either of those dermatologists seeing as I'm, you know, not a dermatologist."

 

[Goro]

What thread?

I made a post in pre-MD to let people who are interested in a career in EM know what they're getting into. But this has to be one of the best SDN threadsever!

 

[that redhead]

I had a septic patient refuse antibiotics until we find out if there's gluten in it

I completely ignored the request for obvious reasons

but then the nurse starts freaking out and gets upset because she might be giving gluten to a gluten-allergic patient

out of overwhelming boredom I ask the pharmacist if it has gluten in it

apparently it did, and so does a few other antibiotics we carry

I don't remember which antibiotics it was because I still don't care, but apparently gluten-free antibiotics is a thing

I had a lady ask if our rabies vaccines were gluten-free...for a dog...

 

[precisiongraphic]

I had a septic patient refuse antibiotics until we find out if there's gluten in it

I completely ignored the request for obvious reasons

but then the nurse starts freaking out and gets upset because she might be giving gluten to a gluten-allergic patient

out of overwhelming boredom I ask the pharmacist if it has gluten in it

apparently it did, and so does a few other antibiotics we carry

I don't remember which antibiotics it was because I still don't care, but apparently gluten-free antibiotics is a thing

I had a lady ask if our rabies vaccines were gluten-free...for a dog...

As a diagnosed celiac (and not a medical professional) these attitudes make me very unhappy. I ask every medical/related professional about gluten in anything that's going into me - dentists, pharmacists and doctors/nurses. Yes, if I'm having a heart attack or a stroke and/or unconscious, then I won't be able to ask about gluten. Otherwise I do. Surely, if I'm septic, my doctor should be able to find me a gluten-free medicine even in an emergency. I went to a Gastroenterology specialist and had an endoscopy and had a diagnosis, by like a real doctor, (sarcasm) and I expect it to be taken seriously.

This flippant attitude toward those diagnosed with celiac and subsequent exposure to gluten is unfortunate. Sure, the Gwyneth Paltrow "I go gluten-free to cleanse my body and lose weight" people make it harder for real celiacs on a day to day basis but they shouldn't affect my medical care. A reasonable question for the doc in the post that I quoted would be to ask "Are you a diagnosed celiac?" before deciding whether to check for gluten.

I'm a bit cranky now because I got exposed to gluten at a restaurant today and will have to spend the next few days running to the restroom - and that was accidental and a likely small amount. I can't imagine how unhappy I'd be in the ER, vomiting and sitting on the toilet while being septic or having a workup for chest pain or whatever. And the nurse was upset because she/he has probably dealt with sick celiacs before and likely the nurse would be the one helping/cleaning up after the celiac while the doctor wouldn't be. I doubt that the accidental exposure would kill me but some celiacs do have seizures and weird neurological symptoms on exposure and I'm not risking that if possible and neither should my doctor.

 

[sunshinefl]

As a diagnosed celiac (and not a medical professional) these attitudes make me very unhappy. I ask every medical/related professional about gluten in anything that's going into me - dentists, pharmacists and doctors/nurses. Yes, if I'm having a heart attack or a stroke and/or unconscious, then I won't be able to ask about gluten. Otherwise I do. Surely, if I'm septic, my doctor should be able to find me a gluten-free medicine even in an emergency. I went to a Gastroenterology specialist and had an endoscopy and had a diagnosis, by like a real doctor, (sarcasm) and I expect it to be taken seriously.

This flippant attitude toward those diagnosed with celiac and subsequent exposure to gluten is unfortunate. Sure, the Gwyneth Paltrow "I go gluten-free to cleanse my body and lose weight" people make it harder for real celiacs on a day to day basis but they shouldn't affect my medical care. A reasonable question for the doc in the post that I quoted would be to ask "Are you a diagnosed celiac?" before deciding whether to check for gluten.

I'm a bit cranky now because I got exposed to gluten at a restaurant today and will have to spend the next few days running to the restroom - and that was accidental and a likely small amount. I can't imagine how unhappy I'd be in the ER, vomiting and sitting on the toilet while being septic or having a workup for chest pain or whatever. And the nurse was upset because she/he has probably dealt with sick celiacs before and likely the nurse would be the one helping/cleaning up after the celiac while the doctor wouldn't be. I doubt that the accidental exposure would kill me but some celiacs do have seizures and weird neurological symptoms on exposure and I'm not risking that if possible and neither should my doctor.

Serious question, would you still react to a parenteral drug??

 

[Perrin]

We have a winner!

 

[precisiongraphic]

Serious question, would you still react to a parenteral drug??

Good question - I don't know. I was told that there is never gluten in IV solutions so that is good. Some things I've seen gluten in (other than OTC advil gel caps etc) are barium solution and antibiotics. It's usually in the binder, not in the active ingredient.

And I do react to topical preparations that have gluten, with a rash.

 

[WilcoWorld]

Serious question, would you still react to a parenteral drug??

Good question - I don't know. I was told that there is never gluten in IV solutions so that is good. Some things I've seen gluten in (other than OTC advil gel caps etc) are barium solution and antibiotics. It's usually in the binder, not in the active ingredient.

And I do react to topical preparations that have gluten, with a rash.

Looking at the pathophysiology of Celiac Disease, it seems unlikely that IV antibiotics given for sepsis would cause bad CD symptoms. As to your first post - please excuse us. We're blowing off steam here. That said, a genuine "I think the antibiotics will be OK. And I'm pretty concerned by your fever, high heart rate and low blood pressure" is more therapeutic than a sigh and an eye roll - the vast majority of us strive to make our patients feel better in the ER, and that includes answering questions.

But when I come here it's with a drink in my hand, and an intention to commiserate with my colleagues about having a tough job, not to be professional.

Lastly, rabies is fatal, and horrifically painful at that. I definitely prefer a month of painful diarrhea to rabies.

 

[sunshinefl]

Looking at the pathophysiology of Celiac Disease, it seems unlikely that IV antibiotics given for sepsis would cause bad CD symptoms. As to your first post - please excuse us. We're blowing off steam here. That said, a genuine "I think the antibiotics will be OK. And I'm pretty concerned by your fever, high heart rate and low blood pressure" is more therapeutic than a sigh and an eye roll - the vast majority of us strive to make our patients feel better in the ER, and that includes answering questions.

But when I come here it's with a drink in my hand, and an intention to commiserate with my colleagues about having a tough job, not to be professional.

Lastly, rabies is fatal, and horrifically painful at that. I definitely prefer a month of painful diarrhea to rabies.

Yes this was the conclusion I reached but I wasn’t being rhetorical/smart mouthed when I asked. IV abx and IM vaccines, even with gluten, I wouldn’t believe would trigger celiac disease. Though I wasn’t specifically told that it wouldn’t (yet? We have immunology/rheumatology right now so maybe I’ll find out) so I asked.

 

[sunshinefl]

Good question - I don't know. I was told that there is never gluten in IV solutions so that is good. Some things I've seen gluten in (other than OTC advil gel caps etc) are barium solution and antibiotics. It's usually in the binder, not in the active ingredient.

And I do react to topical preparations that have gluten, with a rash.

I just saw the edit about the topical preparation. Well, in that case, I would agree with @WilcoWorld that sepsis and rabies would override celiac in risk-benefit analysis.

 

[MechEDoc]

As a diagnosed celiac (and not a medical professional) these attitudes make me very unhappy. I ask every medical/related professional about gluten in anything that's going into me - dentists, pharmacists and doctors/nurses. Yes, if I'm having a heart attack or a stroke and/or unconscious, then I won't be able to ask about gluten. Otherwise I do. Surely, if I'm septic, my doctor should be able to find me a gluten-free medicine even in an emergency.

Be sure to stop by the ER on Vashon Island next time you are septic, they've got a Pyxis full of gluten, nut antigen, and food coloring free medications. One can find a safe and affirming environment for patients that are unvaccinated or are pursuing their own "schedule". The facility is also animal friendly and has fresh water, vegan dog snacks, and hay if you have an animal (both emotional support dog and miniature horses are catered to). Also, there is no fluoride in the water so no worries about triggerring psychogenic non-epileptiform seizures. The NS now has non-iodinated sea salt for its NaCL in case one needs a fluid bolus for their POTS. The ER is fully staffed by NPs, #heartofanursebrainofadoctor!

On a serious note - this is forum for people working health care, and you're jumping on a thread for people to vent after putting up with all sorts of nonsense, probably not a place to expect circumspect discussion nor a place to go all thought police on folks! Pretty much everyone here would be happy to take care of you in an emergency, but probably doesn't memorize IV formulations of drugs by gluten content!

 

[RustedFox]

Some celiacs do have seizures and weird neurological symptoms on exposure and I'm not risking that if possible and neither should my doctor.

No, they don't. If they do; they're pseudoseizures.
Life is not without difficulty. Better to deal with the squirts than gram negative sepsis.

Surely, if I'm septic, my doctor should be able to find me a gluten-free medicine even in an emergency.

No. Such things aren't just readily available in the "other fridge in the pharmacy".

 

[smq123]

Life is not without difficulty. Better to deal with the squirts than gram negative sepsis.

You probably don't get this in the ED that much, but in primary care I'll sometimes get a patient who declares, "I'd rather get cancer than get a mammogram! Cancer is probably less painful!"

Oh, really? You think that metastatic breast cancer is less painful than a mammogram? Hm, interesting.

 

[VA Hopeful Dr]

You probably don't get this in the ED that much, but in primary care I'll sometimes get a patient who declares, "I'd rather get cancer than get a mammogram! Cancer is probably less painful!"

Oh, really? You think that metastatic breast cancer is less painful than a mammogram? Hm, interesting.

I really like the male patients who believe that a colonoscopy might turn them gay

 

[GonnaBeADoc2222]

 

[RustedFox]

"My doctor told to me to come right away for blood pressure treatment!"

BP = 172/88.

PMDs in my neck of the woods don't even manage asymptomatic HTN anymore. They're just "Rx refill" machines.
Can't get a new patient visit because every appointment slot is "med refill" for a retiree/snowbird.

 

[GonnaBeADoc2222]

"My doctor told to me to come right away for blood pressure treatment!"

BP = 172/88.

PMDs in my neck of the woods don't even manage asymptomatic HTN anymore. They're just "Rx refill" machines.
Can't get a new patient visit because every appointment slot is "med refill" for a retiree/snowbird.

I've stopped being diplomatic with this and starting just throwing the referring PCP (usually a midlevel) under the bus. Something like "Sorry this person sent you here for nothing. Guidelines on this changed years ago. Sorry you're going to get a bill for this visit."

People need to open a book before they screw over their patients.

 

[VA Hopeful Dr]

I've stopped being diplomatic with this and starting just throwing the referring PCP (usually a midlevel) under the bus. Something like "Sorry this person sent you here for nothing. Guidelines on this changed years ago. Sorry you're going to get a bill for this visit."

People need to open a book before they screw over their patients.

As a PCP, I am 1000% OK with this. Its one thing if its asymptomatic but running 220/120. I know what the guidelines say, but I can by sympathetic towards outpatient doctors who don't feel OK managing that at first. But stuff like what RF is posting is not OK at all.

 

[BoardingDoc]

some celiacs do have seizures and weird neurological symptoms on exposure and I'm not risking that if possible and neither should my doctor.

I can find lots of results online for gluten induced seizures, but strangely enough I can't find a single one from a reputable source or peer reviewed journal. Maybe I'm just not gluten literate.

 

[smq123]

"My doctor told to me to come right away for blood pressure treatment!"

BP = 172/88.

PMDs in my neck of the woods don't even manage asymptomatic HTN anymore. They're just "Rx refill" machines.

Because it's Florida, the land where you can be ancient and practice medicine from the 1980s, and still have a profitable practice.

 

[RustedFox]

As a PCP, I am 1000% OK with this. Its one thing if its asymptomatic but running 220/120. I know what the guidelines say, but I can by sympathetic towards outpatient doctors who don't feel OK managing that at first. But stuff like what RF is posting is not OK at all.

They're especially bad here. I had one call to tell me she was sending me a needlestick injury... with exposure 3-4 days ago.

"So what do you want me to do with him?"
"Um. I don't know; I don't like, do this."
"So, look up the PEP guidelines and send him to (outpatient lab) have his blood drawn."
"Um. So what drugs for how long ?"
"Here. Let me Google that for you."
"Okay, well I'm sending him anyways for ID consult."
[Lie down. Try not to cry. Cry a lot.]

 

[GonnaBeADoc2222]

As a PCP, I am 1000% OK with this. Its one thing if its asymptomatic but running 220/120. I know what the guidelines say, but I can by sympathetic towards outpatient doctors who don't feel OK managing that at first. But stuff like what RF is posting is not OK at all.

Eh. HTN is a PCPs wheelhouse. "Not feeling OK" means they shouldn't be in the job. All this is is liability shifting to the ED doc. There are crystal clear guidelines on this. Not being able to comprehend science isn't an indication for ED referral. It's like me "not feeling OK" with intubating a person and calling anesthesia. Not acceptable. Not rocket science to start HCTZ and seeing them back in their office in a week.

 

[that redhead]

As a diagnosed celiac (and not a medical professional) these attitudes make me very unhappy. I ask every medical/related professional about gluten in anything that's going into me - dentists, pharmacists and doctors/nurses. Yes, if I'm having a heart attack or a stroke and/or unconscious, then I won't be able to ask about gluten. Otherwise I do. Surely, if I'm septic, my doctor should be able to find me a gluten-free medicine even in an emergency. I went to a Gastroenterology specialist and had an endoscopy and had a diagnosis, by like a real doctor, (sarcasm) and I expect it to be taken seriously.

This flippant attitude toward those diagnosed with celiac and subsequent exposure to gluten is unfortunate. Sure, the Gwyneth Paltrow "I go gluten-free to cleanse my body and lose weight" people make it harder for real celiacs on a day to day basis but they shouldn't affect my medical care. A reasonable question for the doc in the post that I quoted would be to ask "Are you a diagnosed celiac?" before deciding whether to check for gluten.

I'm a bit cranky now because I got exposed to gluten at a restaurant today and will have to spend the next few days running to the restroom - and that was accidental and a likely small amount. I can't imagine how unhappy I'd be in the ER, vomiting and sitting on the toilet while being septic or having a workup for chest pain or whatever. And the nurse was upset because she/he has probably dealt with sick celiacs before and likely the nurse would be the one helping/cleaning up after the celiac while the doctor wouldn't be. I doubt that the accidental exposure would kill me but some celiacs do have seizures and weird neurological symptoms on exposure and I'm not risking that if possible and neither should my doctor.

Celiac disease and gluten sensitivity are extremely rare in dogs, and a vaccine is injectable, not oral. So I’m going to keep my right to eyeroll on that one.

ETA: We do have a number of patients with food allergies, though, and if they have a known food allergy, I do my best to avoid those products/flavors in those dogs. That being said, like @WilcoWorld mentioned, even if I had a dog that somehow did have a gluten allergy and somehow the rabies vaccine might flare that...I'd still give the vaccine, because rabies is a terrible, very preventable disease.

 

[VA Hopeful Dr]

Eh. HTN is a PCPs wheelhouse. "Not feeling OK" means they shouldn't be in the job. All this is is liability shifting to the ED doc. There are crystal clear guidelines on this. Not being able to comprehend science isn't an indication for ED referral. It's like me "not feeling OK" with intubating a person and calling anesthesia. Not acceptable. Not rocket science to start HCTZ and seeing them back in their office in a week.

Lots of PCPs don't have the ability to do any in-house lab testing. How would I make sure there is no end organ dysfunction without that.

 

[Arcan57]

Lots of PCPs don't have the ability to do any in-house lab testing. How would I make sure there is no end organ dysfunction without that.

Unsure if being sarcastic, below presumes this is a genuine question.

End organ dysfunction is quite the sliding scale. If they’re truly asymptomatic, then basically you’re looking for elevated Cr. If you need labs to suspect end organ dysfunction in the CNS or heart then you either suck as a doc or you’re dealing with an ahistoric pt which is not what’s being sent to see me. It’s unlikely you’re going to take someone that’s feeling perfectly fine and admit them to the hospital on the basis of an isolated elevation in Cr.

That visit to the ED to keep from having to order and follow up on lab work is going to cost someone thousands of dollars, possibly lead to unnecesary testing due to triage protocols designed for expediting workups of people actually having emergencies, and have an extraordinary small chance of positively effecting pt outcome.

 

[Rendar5]

Lots of PCPs don't have the ability to do any in-house lab testing. How would I make sure there is no end organ dysfunction without that.

Current EM guidelines indicate no lab testing at all is needed for the essentially asymptomatic pt

 

[VA Hopeful Dr]

Unsure if being sarcastic, below presumes this is a genuine question.

End organ dysfunction is quite the sliding scale. If they’re truly asymptomatic, then basically you’re looking for elevated Cr. If you need labs to suspect end organ dysfunction in the CNS or heart then you either suck as a doc or you’re dealing with an ahistoric pt which is not what’s being sent to see me. It’s unlikely you’re going to take someone that’s feeling perfectly fine and admit them to the hospital on the basis of an isolated elevation in Cr.

That visit to the ED to keep from having to order and follow up on lab work is going to cost someone thousands of dollars, possibly lead to unnecesary testing due to triage protocols designed for expediting workups of people actually having emergencies, and have an extraordinary small chance of positively effecting pt outcome.

Yeah, I basically meant kidneys. Though I have seen offices without ECGs as well (thankfully very rarely).

And you're right, it would be pretty rare for even severely high BP in a healthy patient to be causing problems. But as y'all are quite fond of pointing out, we're expected to never miss anything. So no, I won't fault a PCP for sending in severely elevated BP to y'all. Sending in 180s/100s? No. 220s/120s? Not ideal, but I'm not going to think much of it.

 

[VA Hopeful Dr]

Current EM guidelines indicate no lab testing at all is needed for the essentially asymptomatic pt

No matter how elevated?

 

[Perrotfish]

I've stopped being diplomatic with this and starting just throwing the referring PCP (usually a midlevel) under the bus. Something like "Sorry this person sent you here for nothing. Guidelines on this changed years ago. Sorry you're going to get a bill for this visit."

People need to open a book before they screw over their patients.

Beware of going down this road. I've seen both ER docs and PCPs get burned when their criticism gets reciprocated.

"I'm sorry your ER doctor didn't take your LIFE THREATENING health problem seriously. It could have caused BRAIN DAMAGE, KIDNEY DAMAGE, or DEATH. Here is the website for the hospital administration's complaint line".

Even if you're right its not worth it.

 

[GonnaBeADoc2222]

Yeah, I basically meant kidneys. Though I have seen offices without ECGs as well (thankfully very rarely).

And you're right, it would be pretty rare for even severely high BP in a healthy patient to be causing problems. But as y'all are quite fond of pointing out, we're expected to never miss anything. So no, I won't fault a PCP for sending in severely elevated BP to y'all. Sending in 180s/100s? No. 220s/120s? Not ideal, but I'm not going to think much of it.

Asymptomatic Elevated Blood Pressure

I actually really like your posts and primary care perspectives, but I'm gonna continue to disagree on this one. You don't have to think about it because it gets passed onto us, and then we have to think about it, or actually not think about it at all because these people get discharge paperwork immediately from me. I guess my problem with it is is more from a financial/time cost to the patient and me having to reverse the expectations the PCP gave the patient when they sent them over - all because they are seriously out of date with their knowledge base.

ACEP gives a Level C recommendation to not check serum labs except in select populations (poor follow up - by definition not this circumstance), and a Level C recommendation to initiate long term therapy.

A PCP can easily write of HCTZ and send the patient to the lab to check a BMP.

Beware of going down this road. I've seen both ER docs and PCPs get burned when their criticism gets reciprocated.

"I'm sorry your ER doctor didn't take your LIFE THREATENING health problem seriously. It could have caused BRAIN DAMAGE, KIDNEY DAMAGE, or DEATH. Here is the website for the hospital administration's complaint line".

Even if you're right its not worth it.

Point very well taken.

 

[VA Hopeful Dr]

Asymptomatic Elevated Blood Pressure

I actually really like your posts and primary care perspectives, but I'm gonna continue to disagree on this one. You don't have to think about it because it gets passed onto us, and then we have to think about it, or actually not think about it at all because these people get discharge paperwork immediately from me. I guess my problem with it is is more from a financial/time cost to the patient and me having to reverse the expectations the PCP gave the patient when they sent them over - all because they are seriously out of date with their knowledge base.

ACEP gives a Level C recommendation to not check serum labs except in select populations (poor follow up - by definition not this circumstance), and a Level C recommendation to initiate long term therapy.

A PCP can easily write of HCTZ and send the patient to the lab to check a BMP.

That's the thing, I'm not really disagreeing with you for the most part - interesting link, does make sense from y'all's perspective. Just that I have I guess a higher threshold for getting pissed off at other PCPs (which makes sense, naturally).

 

[Rendar5]

No matter how elevated?

Correct

That said I don’t get upset with PCP’s for sending patients in. The data and recommendations aren’t old enough yet for universal knowledge. It takes something like 18 years for practice changes to disseminate to all fields and the research on this took place in our field. I’ve noticed major practice changes in EM and then Cards and now seeing it start in IM and FM.

 

[Xerxes1729]

I don't mind seeing asymptomatic hypertension. Easy patients. What I don't like is when the RN or MLP gets involved and starts ordering EKGs, trops, head CTs, etc.

 

[GeneralVeers]

I hate HTN patients. In my area they always have the expectation that I'm going to lower it in the ED to a "safe level" before sending them home. It takes a 10-15 minute discussion with these patients and family to reverse their expectations, which usually involves me repeating the evidence over and over until it sinks in. Even then about 50% of my (mostly Hispanic) patients leave disgruntled and upset that I didn't fix their blood pressure. In fact, non-treatment of asymptomatic hypertension is the #1 patient complaint I get, and involves a lot of my time responding to the hospital and my medical director.

So PCPs please get with the 21st century and stop sending these patients in!!!