Why won't Infectious Disease evaluate this possible Lyme Disease patient?

[Gurby]

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Patient is a 25 year old guy who found several ticks attached while biking/camping in an area with high lyme prevalence. Around 1 month later, he developed flu-like symptoms but doesn't remember seeing the EM rash. 3 months later he is now experiencing fatigue, malaise, exertional chest "heaviness", palpitations, dizziness. Western blot is IgG positive for Lyme. He has never been treated for Lyme before.

His primary care is an NP who referred him to Infectious Disease, but when he called to make an appointment they said "we don't treat Lyme disease". He saw a cardiologist who was not willing to start doxycycline (scheduled for stress test and echo 1 month from now...) - cards contacted a friend of his in ID who also refused to see the patient with reason given "we don't see Lyme patients".

I just don't understand why nobody will see/treat this guy - what am I missing here?

He lives in Arizona (was on a trip to New England when bitten by ticks) -- I wonder if providers there are just gun-shy because it's rare to see Lyme there? Maybe they don't want to deal with "chronic lyme"?

 

[NecFasc92]

Also stop muddling your degree with the offensive “providers” phrase unless you actually mean np/pa

 

[kb1900]

It’s the chronic Lyme crap that is going around making people ignore real cases of Lyme.

 

[ndafife]

Because the primary care NP who saw him should be able to start him on doxycycline.

"We don't treat Lyme disease" is code for you are a medical professional , treat your patient.

 

[siliso]

Why would a primary doctor not treat suspected or confirmed Lyme disease? What is an ID consult going to accomplish beside delay in care and more time to develop complications?

 

[Gurby]

Why would a primary doctor not treat suspected or confirmed Lyme disease? What is an ID consult going to accomplish beside delay in care and more time to develop complications?

The primary was an NP, who I guess was uncomfortable treating Lyme because she's based in AZ where they likely don't see it often. I guess an ID consult accomplishes getting him in front of someone who actually knows something about medicine.

 

[siliso]

Rough. Time to fire the NP and go see a doctor, maybe. Like an internist or FP.
ID docs probably screen out “lyme” for same reason as delusional parasitosis. A waste of their resources/time/mental energy. This assumes that a normal PCP can deliver standard care for actual Lyme or actual scabies etc, which sounds like this person has the bad fortune that his cannot,

 

[Mass Effect]

The primary was an NP, who I guess was uncomfortable treating Lyme because she's based in AZ where they likely don't see it often. I guess an ID consult accomplishes getting him in front of someone who actually knows something about medicine.

You made the wrong referral. You need to refer to a legit PCP. There's no reason a PCP shouldn't be able to treat Lyme. Even if he/she hasn't done it before, read, comprehend, and treat.

 

[libertyyne]

Probably the phenomenon of “chronic Lyme” patients. Same reason tons of rheum refuse to see fibro even when some people actually have it

I mean actually having "fibro" is no different than actually not having "fibro" 😉

 

[libertyyne]

You made the wrong referral. You need to refer to a legit PCP. There's no reason a PCP shouldn't be able to treat Lyme. Even if he/she hasn't done it before, read, comprehend, and treat.

This. There is literally no reason why a pcp wont throw doxy at this. Their threshold to throw abx is way lower than ID.

Also another reason to never go to an NP when you are actually sick.

 

[Angus Avagadro]

There are criteria for diagnosing and treating lyme disease. Anyone calling themselves a PCP should be aware of them and be able to treat. It's an easy Google for the uninformed.

 

[jdh71]

Patient is a 25 year old guy who found several ticks attached while biking/camping in an area with high lyme prevalence. Around 1 month later, he developed flu-like symptoms but doesn't remember seeing the EM rash. 3 months later he is now experiencing fatigue, malaise, exertional chest "heaviness", palpitations, dizziness. Western blot is IgG positive for Lyme. He has never been treated for Lyme before.

His primary care is an NP who referred him to Infectious Disease, but when he called to make an appointment they said "we don't treat Lyme disease". He saw a cardiologist who was not willing to start doxycycline (scheduled for stress test and echo 1 month from now...) - cards contacted a friend of his in ID who also refused to see the patient with reason given "we don't see Lyme patients".

I just don't understand why nobody will see/treat this guy - what am I missing here?

He lives in Arizona (was on a trip to New England when bitten by ticks) -- I wonder if providers there are just gun-shy because it's rare to see Lyme there? Maybe they don't want to deal with "chronic lyme"?

This is basically asking ID to treat community acquired pneumonia or cellulitis. It’s not a complicated infection that requires deep thoughtful or long term management. Furthermore some patients develop a post Lyme infectious syndrome which they incorrectly think is a chronic infection and that is also not something that should be managed by an infectious disease specialist and is totally primary care wheelhouse.

 

[deleted610572]

How the hell can a supposed primary care person (NP) not able to treat Lyme. Lol. Even if you didn’t understand the disease at all, which I’m not doubting is the case, there is an actual algorithm on up to date. We all know how midlevels love protocols

 

[mistafab]

”PCP” can’t treat lyme?

 

[Gurby]

Thanks for the insight everyone. The whole thing is FUBAR.

He can't get another appointment at his normal clinic for weeks, and he's seen some more useless midlevels at urgent care who have refused to treat because his primary didn't... He did manage to find an actual doctor to see him this coming week, so hopefully he doesn't develop more complications before then.

 

[Neopolymath]

I don't understand. 1st year medical students know to use doxy on this. I have been around bad midlevels but this is, uh, startling at best. What is the ”real" drawback of starting him on doxy for the NP? Nothing beside antibiotic stewardship if 0.00001% wrong.

 

[Chibucks15]

I had an NP ask a doc if you give magnesium for hypertension during eclampsia. Didn’t even register that mag isn’t even close to treating blood pressure. It’s an epidemic

 

[Giovanotto]

I had an NP ask a doc if you give magnesium for hypertension during eclampsia. Didn’t even register that mag isn’t even close to treating blood pressure. It’s an epidemic

There are studies supporting the use of magnesium for prevention of eclampsia, but also for its vasodilatory functions. However, it's more commonly used in preclampsia for seizure prophylaxis and as an abortive.

 

[Chibucks15]

There are studies supporting the use of magnesium for prevention of eclampsia, but also for its vasodilatory functions. However, it's more commonly used in preclampsia for seizure prophylaxis and as an abortive.

Yeah I guess what I meant was she had no idea about the seizure prophylaxis as the reason to give it in pre E. She was in no way up to date on studies with vasodilatory effects and all that haha she was saying mag as a first line for BP which is something I’d never heard of

 

[Medic741]

This thread made me curious about chronic Lyme disease and found a really good review article for anyone interested

Chronic Lyme Disease - PMC

www.ncbi.nlm.nih.gov

 

[deleted645092]

+1 to ID not treating it because this isn’t an ID issue; They aren’t there to treat every infection that comes along, they’re there to treat the complicated + rare + deadly infections that require complicated and/ or chronic management. This is the equivalent of referring to cardiology for initial hypertension management.

 

[watermelon master]

I had an NP ask a doc if you give magnesium for hypertension during eclampsia. Didn’t even register that mag isn’t even close to treating blood pressure. It’s an epidemic

I'm all for accountability and keeping up to date on things but why are you using this example to rag on NPs? I thought magnesium lowered blood pressure and when I read your comment it confused me since I didn't really understand what the problem is.

Magnesium sulfate in emergency department patients with hypertension - PubMed

To compare the effect of IV magnesium with other antihypertensives in emergency department (ED) patients with hypertension. ED patients with a systolic BP > 135 mmHg or diastolic BP > 85 were approached for entry into the study. Those granting consent were randomly placed into one of three tre …

www.ncbi.nlm.nih.gov

This study shows that MgSO4 lowers blood pressure in hypertensive patients in the emergency department.

Again going back to the question, why is it such a bad question to ask if you give magnesium to patients who have eclampsia for their hypertension?

 

[Medic741]

Yeah I guess what I meant was she had no idea about the seizure prophylaxis as the reason to give it in pre E. She was in no way up to date on studies with vasodilatory effects and all that haha she was saying mag as a first line for BP which is something I’d never heard of

Yikes. Let that sink in for a second. Jesus...

 

[7331poas]

I'm all for accountability and keeping up to date on things but why are you using this example to rag on NPs? I thought magnesium lowered blood pressure and when I read your comment it confused me since I didn't really understand what the problem is.

Magnesium sulfate in emergency department patients with hypertension - PubMed

To compare the effect of IV magnesium with other antihypertensives in emergency department (ED) patients with hypertension. ED patients with a systolic BP > 135 mmHg or diastolic BP > 85 were approached for entry into the study. Those granting consent were randomly placed into one of three tre …

www.ncbi.nlm.nih.gov

This study shows that MgSO4 lowers blood pressure in hypertensive patients in the emergency department.

Again going back to the question, why is it such a bad question to ask if you give magnesium to patients who have eclampsia for their hypertension?

Guy who just passed M1 with the big dick energy

 

[Chibucks15]

I'm all for accountability and keeping up to date on things but why are you using this example to rag on NPs? I thought magnesium lowered blood pressure and when I read your comment it confused me since I didn't really understand what the problem is.

Magnesium sulfate in emergency department patients with hypertension - PubMed

To compare the effect of IV magnesium with other antihypertensives in emergency department (ED) patients with hypertension. ED patients with a systolic BP > 135 mmHg or diastolic BP > 85 were approached for entry into the study. Those granting consent were randomly placed into one of three tre …

www.ncbi.nlm.nih.gov

This study shows that MgSO4 lowers blood pressure in hypertensive patients in the emergency department.

Again going back to the question, why is it such a bad question to ask if you give magnesium to patients who have eclampsia for their hypertension?

The protocol states labetolol, at least at my hospital. You don't treat pre-E with mag alone for HTN, you add the mag for neuroprotective features

 

[watermelon master]

Guy who just passed M1 with the big dick energy

and a 260+ on step 1

 

[7331poas]

and a 260+ on step 1

im talking about the guy you are quoting

 

[Chibucks15]

im talking about the guy you are quoting

Me? I'm an M3 but if you're still upset about me calling you out on your anki worship that's cool

 

[7331poas]

Me? I'm an M3 but if you're still upset about me calling you out on your anki worship that's cool I'll respect your ego

Apologies. OMS3 with the big dick energy calling out providers for not knowing a guideline. Classic.

 

[Chibucks15]

Apologies. OMS3 with the big dick energy calling out providers for not knowing a guideline. Classic.

Eh I didn't think it was gonna cause this big stir. My point was if an M3 can get a question right about primary function of a drug, that an NP couldn't then that's usually an issue. Mag isn't a first line BP agent (even if it has vasodilatory properties, there's no way in hell she knew that or else she would've said that). She also had no idea about the neuroprotective aspect of it. Which was my main point. I don't see why that's a hard concept to grasp. But sorry I didn't mean to offend you!!! I suppose my inferior intellect will just have to stay quiet from now on

 

[werd]

I can understand why ID may have a policy of not treating Lyme. It's like having a patient with culture-confirmed Strep throat... don't refer to ID, just treat the infection; there's nothing exotic about how to treat this.
Real Lyme disease can be tricky to diagnose at times, especially when the classic EM rash never occurs. But once a diagnosis is known the treatment guidelines are straightforward. however, delusion of chronic/intractable/uncurable Lyme disease is a significant problem. I imagine some ID offices won't see Lyme disease because they were getting bogged down with "uncurable Lyme disease" patients.

 

[allantois]

Docs in my area don't screen out patients for anything as it's a pretty bad business practice for them when they start loosing referrals

 

[Neopolymath]

Docs in my area don't screen out patients for anything as it's a pretty bad business practice for them when they start loosing referrals

I don't know if you are referring specifically to private practice docs in your area but I would agree. Outside academics, stupid consults are easy money and most people I know are happy to spend the short time doing them because it's good customer service for the good referrals.

 

[ndafife]

I don't know if you are referring specifically to private practice docs in your area but I would agree. Outside academics, stupid consults are easy money and most people I know are happy to spend the short time doing them because it's good customer service for the good referrals.

Nothing like billing a specialty visit to fill a prescription for a known diagnosis that the primary care person should have prescribed to help keep down rising medical costs in this country

 

[Neopolymath]

Nothing like billing a specialty visit to fill a prescription for a known diagnosis that the primary care person should have prescribed to help keep down rising medical costs in this country

boat payment isn't going to figure itself out

 

[VA Hopeful Dr]

Docs in my area don't screen out patients for anything as it's a pretty bad business practice for them when they start loosing referrals

I've never met an ID doctor who cared about this as its rare outside of major cities to have multiple ID options.

 

[allantois]

I've never met an ID doctor who cared about this as its rare outside of major cities to have multiple ID options.

Most IDs here do primary care as there are just not enough ID only cases to go around..

 

[VA Hopeful Dr]

Most IDs here do primary care as there are just not enough ID only cases to go around..

Same, though some only do primary care for their HIV patients not as a general PCP type