What do other providers do routinely that you just hate?

[Reality Check 2]

A few clonidine will get it down. On a related note, dialysis clinics are springing up like weeds.

The rebound with clonidine is dangerous.

If you use it you have to have other meds going on board to keep it down.

I personally hate clonidine but hate it less than the old nifedipine under the tongue routine. 

A lot of patients are off their meds for a variety of reasons and that goes back to good FP management and education - unfortunately  - there aren't enough of us FP folks around to take care of all these people.

[sas5814]

The rebound with clonidine is dangerous.

If you use it you have to have other meds going on board to keep it down.

I personally hate clonidine but hate it less than the old nifedipine under the tongue routine. 

A lot of patients are off their meds for a variety of reasons and that goes back to good FP management and education - unfortunately  - there aren't enough of us FP folks around to take care of all these people.

took the words right out of my mouth. people get a clonidine and get sent home. Rebound. Have even higher BP and are lost to follow up because it was "fixed" at the UC or in the ER.  Our policy is simple see your PCP unless you have indications for intervention now and those patients get sent from the UC to the ER.

I thought the Nifedipine thing was shrugged off 20 years ago.

[Reality Check 2]

took the words right out of my mouth. people get a clonidine and get sent home. Rebound. Have even higher BP and are lost to follow up because it was "fixed" at the UC or in the ER.  Our policy is simple see your PCP unless you have indications for intervention now and those patients get sent from the UC to the ER.

I thought the Nifedipine thing was shrugged off 20 years ago.

I am old - I remember when Nifedipine was "novel" and a really good plan. Ummm, not really. It failed. 

 

This BP thing reminds me of hypoglycemia. We used to get folks in the ER and they were not diabetic and hypoglycemic - as in 30-40 on glucose  - or were diabetic and hypoglycemic. A lot of providers would "correct" the low sugar without looking for a reason behind it - sepsis, UTI, self harm, stupidity, etc. Too many folks got sent out of the ER with sugars above 70 but no long term investigation or intervention. Often wondered what happened to those folks. I always kept mine until I got a glimmer of why and helped correct with simple things like food and monitoring.

 

Same with BP. Don't just bandaid - at least try to figure out the WHY and try to keep it from happening again. 

 

So, I would want other providers to do the same.

[GetMeOuttaThisMess]

took the words right out of my mouth. people get a clonidine and get sent home. Rebound. Have even higher BP and are lost to follow up because it was "fixed" at the UC or in the ER. Our policy is simple see your PCP unless you have indications for intervention now and those patients get sent from the UC to the ER.

I thought the Nifedipine thing was shrugged off 20 years ago.

Yours truly has seen a patient gorked with the SL nifedipine. Obtained a great "normal" BP but it was "hypotensive" to the patient. They didn't recover. Older patient and only one 10 mg SL dosing.

[Acebecker]

I really hate taking on new patients from other docs/PAs/NPs who wrote in their notes under surgical history, medical history, family history, or social history anything like the following - "Please see personal health history questionnaire."  That is not history taking. 

 

My other favorite, under surgical history, "None" when the patient has a gnarly old school chole scar, bilateral TKAs, a total hip, and has had a CABG.  

[Reality Check 2]

You know the chart isn't going to help when it says:

 

Family history - noncontributory - meaning - never asked or wrote anything down.

 

WNL for ANYTHING - it stands for "we never looked"

 

Or if they cut and paste templates stating a patient with a real migraine looks "well nourished in no distress" - last migraine I had my nourishment state didn't matter a tinker's damn - my head was going to explode and I was indeed a tad distressed. 

 

I like real descriptors. 

 

"pleasant middle aged female with pigtails wearing monkey slippers" tells me more than a lot of other notations.

 

Paint a picture and quit using the stupid click drop down crap.

[GetMeOuttaThisMess]

You know the chart isn't going to help when it says:

 

Family history - noncontributory - meaning - never asked or wrote anything down.

 

WNL for ANYTHING - it stands for "we never looked"

 

Or if they cut and paste templates stating a patient with a real migraine looks "well nourished in no distress" - last migraine I had my nourishment state didn't matter a tinker's damn - my head was going to explode and I was indeed a tad distressed.

 

I like real descriptors.

 

"pleasant middle aged female with pigtails wearing monkey slippers" tells me more than a lot of other notations.

 

Paint a picture and quit using the stupid click drop down crap.

This right here is the reason that I have an H&P written out on my elderly mom that I can access if hospitalization were to be required, or if for whatever reason I'm inaccessible, my brother is backup MPA and has access to all forms/documents including this H&P.

[d2305]

It was sublingual nifedipine that has a rebound.

[sas5814]

Rebound wasn't the right word for clonidine. More like it wears off in 8 hours but the patient thinks everything is fixed and they get lost to follow up. Bottom line there are only a few circumstances where urgent intervention of elevated BP is of any real benefit to the patient.

[Guest JMPA]

maybe only a few for urgent BP treatment but those few can be mortal real fast.

[Reality Check 2]

Around my area there doesn't seem to be a consensus or protocol for ER BP and that frustrates me.

 

Some patients with 162/98 get the full banana with urine microalbumin in the ER, CMP, EKG, clonidine in the ER with a dose of ACE or beta blocker or something and then sent with 30 days of meds to PCP or to find PCP.

 

Other patients with 180/110 don't get a workup and get sent home with lisinopril 10 mg and no instructions. 

 

So, if we go back to OP inquiry about what other providers do that bugs me ---- not consistent and patients never seem to understand. All they hear is "you didn't have a stroke but could if you don't get your BP down". 

 

I would love to see some sort of consistency in the decision making and level of workup or lack thereof. 

[Evolute]

The only indication for quick intervention, at least according to an article I read a few days ago, is indication of end organ damage or some kind of related symptoms. Outcome with and without immediate intervention is otherwise the same. I work in UC and we get patients in daily for "high blood pressure this morning." 180/96, asymptomatic. "See your PCP"

I completely agree. We get asymptomatic patients in the ED all the time with htn sent in by their pcp or uc. I say yeah your BP is to high in the long run but it's not high enough to treat in the ED. You have no signs of end organ damage. Follow up with your pcp..... then they get pissed b/c their pcp told them to go to the ED. So now they get an additional ED bill. Thanks for the extra several hundred dollar bill.. ...

[sk732]

This was a topic of discussion at the conference I was at a couple weeks ago...seems our BP's are generally higher as a result of these visits than the patients'.  I've seen the odd hypertensive emergency - my brother presented to ED with a BP of "Patent Pending"/200 and something and was walking into walls - his was his initial presentation of Berger's disease, but most presentations aren't that dramatic of hypertension.  Unless the "Am I going to lose sleep tonight?" rule is violated, they'll get a couple of BP checks (maybe) and we'll chat a bit before they go home...

 

SK

[GreatChecko]

I really hate it when an MD has some concern, and instead of mentioning it, asking me about it, or just discussing it, they barge into the room, don't acknowledge me, interrupt the H&P, ask the same questions, formulate the same plan, then tell me to, "Make sure to do...", and then act like I'm supposed to keep the patient.

 

I just smile and say, "Well sir, it looks like you really want to see this patient yourself...," and hand them the chart. 

 

Figured out the last one, but this time I'm still working out how to get the new one to stop his bad habits.

[Reality Check 2]

Renewal of old issue.

 

We have only 3 GI groups in town. 

 

One of them wants the PCP to give scope results to the patient.  Ummmmm - NO.

 

I sent them a patient for esophageal dysmotility and dysphagia. They did EGD and biopsies. Never sent me notes.

 

The patient calls me saying she was told to call me for pathology and a plan.

 

A PLAN?  WHY did I send the patient to GI in the first place???? 

 

I called their office manager and told her under no uncertain circumstances would I do their job for them. Couldn't get a doc on the phone. They don't talk to people.

If one of their GI docs or PAs does something or sees the patient - then they see it through and actually do something if indicated to treat the patient.

 

I never use this group as a general rule but had to send her there as she works for their corporate overlord. 

 

GGGGGRRRRRRR

[RetNavyPAC]

The only indication for quick intervention, at least according to an article I read a few days ago, is indication of end organ damage or some kind of related symptoms. Outcome with and without immediate intervention is otherwise the same. I work in UC and we get patients in daily for "high blood pressure this morning." 180/96, asymptomatic. "See your PCP"

 

One of the best EM lectures (and most useful) I ever heard was Rob Rogers' (then at U of Md) "Asymptomatic HTN in the ED: Don't Just Do Something, Stand There."

[sas5814]

One of the best EM lectures (and most useful) I ever heard was Rob Rogers' (then at U of Md) "Asymptomatic HTN in the ED: Don't Just Do Something, Stand There."

Holy crap that is the first time I actually laughed out loud at a post! I am so stealing that.

[Katera]

I completely agree. We get asymptomatic patients in the ED all the time with htn sent in by their pcp or uc. I say yeah your BP is to high in the long run but it's not high enough to treat in the ED. You have no signs of end organ damage. Follow up with your pcp..... then they get pissed b/c their pcp told them to go to the ED. So now they get an additional ED bill. Thanks for the extra several hundred dollar bill.. ...

 

 

 

Or thousands.....

 

 

 

 

 

and for the record I hate Clonidine.  I'm with the above posters, didn't we get rid of that crap 20 years ago in the ED?  I recently played a hand in getting it removed from the UC I work in.  UC has NO business using that stuff...