What would you have done?

[Wish1pa]

I work in primary care now but pick up shifts occasionally at the urgent care I used to work at. Saw a 62 yo lady at the UC today who came in for refills of her prescriptions: hctz, amlodipine-Valsartan, metoprolol (all for her HTN), metformin and simvastatin. BP was 212/115, sugar was 364 NF. She complained of no symptoms, just needed refills because she was having trouble finding a new PCP with her insurance. Did ekg despite her protests,  HR 102 and LVH with evidence of Myocardial infarction (possibly old). I gave her a clonidine (at the suggestion of my SP) to bring it down and Of course I advised her to go to ER which she refused so I had her sign AMA. I refilled her meds anyway because I felt like not doing so would be causing harm. Would you have done anything differently? Was the clonidine plus all those meds overkill? I get nervous about cases like this even with the AMA form but I didn’t want to just send her home without her meds which she needs.

This is why I can’t stand UC anymore (that and the 5 or 6 cold symptoms x 2 days pts)

[mgriffiths]

I don't understand why patients are coming to an UC for med refills.  There is absolutely no way to review their full medical history, medication history, etc. in an UC appointment.  I also work in FP and have started covering a local UC here and there...I would not have refilled her medications.  It has nothing to do with her current symptoms and medical issues, it's that by filling them I am setting up a patient-provider relationship for her to begin abusing the UC for chronic medications.  Maybe I'm wrong...

As for her BP and ECG, you can only educate as best as you can and make your recommendation.  It is up to the patient to follow through.  You just have to make sure you document like you have never documented before!!

[JustinPA]

I don't really think there is a benefit to administering clonidine or doing an EKG for asymptomatic hypertension.  There's nothing wrong with refilling her meds for 7-10 days and giving her information for a local PCP.  

"In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required. (2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission)."

"(1) In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. (2) In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control."

https://www.acep.org/patient-care/clinical-policies/asymptomatic-elevated-blood-pressure/#sm.000r7hbwf19sffdj106hb7uklsfu6

[ohiovolffemtp]

Wish,

You did the right things: you evaluated her within the capabilities of the UC.  The clonidine is a temporary fix, but commonly done.  She's better off for you refilling her meds than turning her away.  If she signs the AMA that still doesn't mean don't treat her.  You did what she would let you.

[Probasesteal]

I would have done the same. Did you recheck BP after clonidine or let her go? I'm curious what dose you gave?

[UGoLong]

I don't understand why patients are coming to an UC for med refills.  There is absolutely no way to review their full medical history, medication history, etc. in an UC appointment.  I also work in FP and have started covering a local UC here and there...I would not have refilled her medications.  It has nothing to do with her current symptoms and medical issues, it's that by filling them I am setting up a patient-provider relationship for her to begin abusing the UC for chronic medications.  Maybe I'm wrong...
As for her BP and ECG, you can only educate as best as you can and make your recommendation.  It is up to the patient to follow through.  You just have to make sure you document like you have never documented before!!

Someone with uncontrolled HTN and no meds needs enough meds to tide them over to see the prescribing provider. Clonidine is also OK as a one-timer until she gets to the pharmacy.

Sometimes we just have to do our best, in spite of the situation.


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[thinkertdm]

Clonidine has a short half life with possibility of rebound hypertension.  Rebound hypertension unlikely after a single dose, though. No benefit for this asymptomatic lady to bring her blood pressure down so fast, but there is possibility of stroke.

It essentially did nothing except make you feel better that you did something.  Blood pressures are like cruise ships; you gotta guide them, and they don't make sudden changes.

It's interesting that your sp recommended clonidine but no short acting insulin.

Also- I'm not sure even the Ed would be able to do any more.  

Incidentally, while many people are on multiple antihypertensives, she may be on multiple simply because she is noncompliant, and her previous doc just kept adding more 

[ohiovolffemtp]

In the ED I would have done some screening labs: CBC, BMP, trop, UA (looking for, really r/o, proteinuria), 12 lead, CXR, maybe BNP if lower leg edema or lungs sound wet.  Mostly to make sure no badness missed.  After all, where is every one sent as last resort....

[medic25]

Refill her meds and if possible help her get primary care access. Absolutely no reason to send an asymptomatic hypertension patient to the ED; this is a huge frustration for us when these patients are sent in by UC or PCP.


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[LT_Oneal_PAC]

2 hours ago, medic25 said:

Refill her meds and if possible help her get primary care access. Absolutely no reason to send an asymptomatic hypertension patient to the ED; this is a huge frustration for us when these patients are sent in by UC or PCP.


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agreed with this. Did the right thing refilling her meds. Not that UC appointment length is amenable to this, but I might have asked her insurance and helped her shop. I wouldn't have given clonidine. Not that it hurt her, just don't think it helped. 

[rev ronin]

The only thing I would add to the above advice is a STOP BANG for sleep apnea screening.  It's simple to do, surprisingly often undiagnosed sleep apnea is connected to multidrug-resistent "essential" hypertension, and despite the difficulties with follow up, if she actually gets screened and treated, there's a chance a whole lot of things will start going RIGHT for her healthwise.

[Wish1pa]

8 hours ago, Probasesteal said:

I would have done the same. Did you recheck BP after clonidine or let her go? I'm curious what dose you gave?

I gave 0.1 mg. We didn’t recheck because by the time the ekg was done she was agitated and just wanted to go. Normally I would have had them wait a bit and recheck 

[Guest ral]

I am surprised nobody mentioned this (or I missed it) but, what is the policy of your UC when it comes to patients with this presenting complaint?  "I just need a refill on all my medicine." should have been met at the point of check in with, "I am sorry but, we do not refill chronic meds."   Patient shouldn't have made it to a room for you to see them.

[sas5814]

We don't refill meds in the UC. One of our better policies. I think its a split decision on whether filling them of not filling them is the greatest liability. Either way things can go bad. 

[CAdamsPAC]

9 hours ago, medic25 said:

Refill her meds and if possible help her get primary care access. Absolutely no reason to send an asymptomatic hypertension patient to the ED; this is a huge frustration for us when these patients are sent in by UC or PCP.


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A lifetime ago when I worked in your ED, my SP & ED Director felt refilling chronic medication in the ED was a set up for litigation. He felt by conducting PC activity when you will not be following the pt is bad medicine.

[jmj11]

She has a primary care (or internal medicine) problem, but has no access. That is a real problem for patients where practices are not accepting any new patients with their insurance. No, UC or ER is not the place for refills. I have good insurance but found that it takes a month to get in to see my PCP for an acute problem. My wife recently had the same problem. The system is broken.

[Cideous]

Well as someone who has been around UC for a long time I can tell you this.  

1.  No WAY in the world I am refilling anything of hers.  You have now inserted yourself into her chronic care regiment which is in obvious disarray.  If she strokes at home, your name is on the last pill bottle given.

2.  I would of told her I was going to call EMS to transport to the ER and if she denied I would of had her sign a refusal of EMS transport AMA along with the refusal to go to the ER for care AMA.

3.  No way I am giving Clonidine.  We actually removed it from our clinics.  She should be in the ED having her BP lowered slowly at those numbers.  Throwing a half measure Clonidine at her and hoping for the best, once against put you in a really bad spot if she crashes.

3.  I would of wrote a long note on her discharge paperwork ending with "up to and including death.." on her discharge papers.  Something you can prove you gave her.

 

This is the kind of crap I see all the time now in UC and by being "the nice guy" by refilling her meds, you thrust yourself right smack dab in the middle of her health tornado.  The acuity of UC patients has skyrocketed the last 7 years, but you are putting yourself in an indefensible position by inserting yourself in a half-measure treatment if she drops.  

 

Just my 2 cents.

[rev ronin]

I will refill meds in walk-in for chronic conditions that I would myself prescribe, typically for a month, but zero controlled substances.  I do make it very clear in my chart notes that we're not changing anything as we don't have labs and history available to do so, and our chart notes get faxed to the PCPs practice.  If it was a potentially dangerous medication (e.g., >150 mcg of Levothyroxine) or a med I don't usually start, I might give less, get labs done, or some other mitigation.  But yeah, if you show up and want Atorvastatin and Losartan, I'm not going to kick you to the curb.

Sure, I might be helping a patient badly manage their own conditions, but on the balance of harms, I'm much more likely to be helping them get access when the good PCPs are all overwhelmed!  Also, I don't see medicaid in walk-in, so 100% of my patients have to pay SOMETHING to go get the prescriptions I write for them, which gives me some confidence they're in for the right reasons.

[Wish1pa]

10 hours ago, ral said:

I am surprised nobody mentioned this (or I missed it) but, what is the policy of your UC when it comes to patients with this presenting complaint?  "I just need a refill on all my medicine." should have been met at the point of check in with, "I am sorry but, we do not refill chronic meds."   Patient shouldn't have made it to a room for you to see them.

We don’t really have a policy unfortunately. They’re kinda like, encourage the patient to find a pcp but still refill their meds. It’s the kind of business that doesn’t like to turn patients away if you know what I mean.

the best part was when I said ok I’m going to do an ekg she said I was only doing an ekg to get more money from her. I’m like lady I don’t get any financial gain from doing an ekg and plus it’s included in your copay

[ventana]

thoughts

our system is broken

you can't NOT fill her scripts - how does this sound "sorry judge I didn't fill her HTN and DM meds as i am not a PCP"  (on trial for a wrongful death due to DKA or CVA or MI - - you can't not treat what is in front of you and she is HTN and DM

Yup it sucks, but you have a DEA, and License and the training to help her

 

I would have approached it a little differently - a missing fact - WAS SHE OUT OF HER MEDS AND IF SO HOW LONG?

 

You would expect HTN and elevated sugars if she was out of her meds and had been for a little while - think 3-5 days

 

I would have refilled, and given her a sheet listing local PCP's, and had her sign AMA if you had EKG? of infarction (don't order the EKG next time - she had no complaints - all you did was increase your liability)

Then I would have sat with her and called some of the PCP's on the list and gotten her set up with a more urgent appointment - in 2-3 weeks MAX - sometimes the provider being on the phone really does help!!

 

 

[WeBuyAndSellJunk]

39 minutes ago, ventana said:

I would have approached it a little differently - a missing fact - WAS SHE OUT OF HER MEDS AND IF SO HOW LONG?

 

 

The complexity of this case changes a ton based on that fact alone. She is either uncontrolled with what sounds like resistant hypertension or she just ran out of meds. The latter situation with some simple refills may leave her perfectly stable and not needing urgent follow-up. 

The real question is why can’t she find a PCP? This is where you can shine and have an office manager or knowledgable MA get an appointment scheduled for you. Make some calls and help this lady get follow-up. People don’t get sued for helping, they get sued for blatantly poor decisions and for having awful bedside manners. It doesn’t sound like this is either situation and a jury is likely to feel similarly.

From the PCP perspective, change that beta blocker to spironolactone and if that doesn’t fix the problem, she needs a secondary HTN work-up. Of course, the diabetes needs managed better too and is likely a large component.

 

 

[Wish1pa]

14 hours ago, printer2100 said:

The complexity of this case changes a ton based on that fact alone. She is either uncontrolled with what sounds like resistant hypertension or she just ran out of meds. The latter situation with some simple refills may leave her perfectly stable and not needing urgent follow-up. 

The real question is why can’t she find a PCP? This is where you can shine and have an office manager or knowledgable MA get an appointment scheduled for you. Make some calls and help this lady get follow-up. People don’t get sued for helping, they get sued for blatantly poor decisions and for having awful bedside manners. It doesn’t sound like this is either situation and a jury is likely to feel similarly.

From the PCP perspective, change that beta blocker to spironolactone and if that doesn’t fix the problem, she needs a secondary HTN work-up. Of course, the diabetes needs managed better too and is likely a large component.

 

 

She says she ran out of her HTN meds 3 days prior, the others about a week prior. She couldn’t find a pcp because 1. She only wanted a female provider 2. She has a crappy Medicaid plan 3. She was busy going back and forth to New Jersey because both of her parents passed away. So I did  feel bad. And It was a Sunday so I don’t think any pcp offices were open that day. But she said she was willing to see a male and had a couple names she was going to call 

[medic25]

On 2/18/2019 at 10:24 AM, CAdamsPAC said:

A lifetime ago when I worked in your ED, my SP & ED Director felt refilling chronic medication in the ED was a set up for litigation. He felt by conducting PC activity when you will not be following the pt is bad medicine.

Nothing on the books these days.  I rarely do refills, and never on controlled substances, but if someone has a rational explanation (e.g. visiting the area and forgot meds at home) I'll do a short supply of maintenance meds.

[medic25]

On 2/18/2019 at 10:56 AM, Cideous said:

 

2.  I would of told her I was going to call EMS to transport to the ER and if she denied I would of had her sign a refusal of EMS transport AMA along with the refusal to go to the ER for care AMA.

Just wondering what the rationale is for calling EMS and sending her to the ER?  The patient has no physical complaints and some chronic health conditions; not sure I see the benefit in tying up a 911 unit and adding to her medical bills when there isn't anything emergent to address.

[EMEDPA]

Agree with medic 25- If you forgot your atenolol, sure. if you forgot your percocet you are out of luck(unless I talk to your oncologist and he asks me to help out with a few doses).