Guest ral Posted February 19, 2019 Share Posted February 19, 2019 2 hours ago, Wish1pa said: She says she ran out of her HTN meds 3 days prior, the others about a week prior... I have had patients show up at 2300hrs in the ER, with a complaint that they ran out of their medicine earlier that day. Me: How long have you been on this medication? Pt: About seven or eight years. Me: And how often do you take it? Pt: Twice daily. Me: So, you've been taking the medicine for many years, twice daily, and when you took this morning's dose, and saw one pill left in the bottle, you couldn't deduce that you would be out of medication after tonight? You're essentially telling me that you cannot count to one, two at best? Perhaps you should be wearing a helmet. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 19, 2019 Share Posted February 19, 2019 I have had patients show up at 2300hrs in the ER, with a complaint that they ran out of their medicine earlier that day. Me: How long have you been on this medication? Pt: About seven or eight years. Me: And how often do you take it? Pt: Twice daily. Me: So, you've been taking the medicine for many years, twice daily, and when you took this morning's dose, and saw one pill left in the bottle, you couldn't deduce that you would be out of medication after tonight? You're essentially telling me that you cannot count to one, two at best? Perhaps you should be wearing a helmet.You’re asking way too much of me. Can you help me get a helmet? Link to comment Share on other sites More sharing options...
sas5814 Posted February 19, 2019 Share Posted February 19, 2019 1 hour ago, ral said: I have had patients show up at 2300hrs in the ER, with a complaint that they ran out of their medicine earlier that day. Me: How long have you been on this medication? Pt: About seven or eight years. Me: And how often do you take it? Pt: Twice daily. Me: So, you've been taking the medicine for many years, twice daily, and when you took this morning's dose, and saw one pill left in the bottle, you couldn't deduce that you would be out of medication after tonight? You're essentially telling me that you cannot count to one, two at best? Perhaps you should be wearing a helmet. One of the reasons I hated call when I was in FP. Saturday night at 11 PM you get the call because "Momma is out of her BP meds". It wasn't important enough to keep track of but became critical on the weekend. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted February 19, 2019 Share Posted February 19, 2019 1 hour ago, medic25 said: 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. Reasonable Link to comment Share on other sites More sharing options...
CAdamsPAC Posted February 19, 2019 Share Posted February 19, 2019 1 hour ago, ral said: I have had patients show up at 2300hrs in the ER, with a complaint that they ran out of their medicine earlier that day. Me: How long have you been on this medication? Pt: About seven or eight years. Me: And how often do you take it? Pt: Twice daily. Me: So, you've been taking the medicine for many years, twice daily, and when you took this morning's dose, and saw one pill left in the bottle, you couldn't deduce that you would be out of medication after tonight? You're essentially telling me that you cannot count to one, two at best? Perhaps you should be wearing a helmet. And why should a patient be expected to take responsibility for their care?? Link to comment Share on other sites More sharing options...
Guest ral Posted February 19, 2019 Share Posted February 19, 2019 1 hour ago, GetMeOuttaThisMess said: You’re asking way too much of me. Can you help me get a helmet? I believe helmets fall under the same category as diabetic shoes. I'm just a PA, and cannot write for one. You'll have to see your PCP. Link to comment Share on other sites More sharing options...
Cideous Posted February 19, 2019 Share Posted February 19, 2019 3 hours ago, medic25 said: 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. 62 y/o High liability Diabetic (uncontrolled) Higher liability 212/115? Seriously? In a diabetic? Just giving Clonidine and sending her home? LOL you guys have bigger nuts then me I guess just sending her home from an Urgent Care. You did see she was an uncontrolled diabetic and know what the definition of a hypertensive emergency is?....and 62? No way she doesn't at least get offered and documented an EMS denial AMA ride to the ED. If this was a patient you had seen many times and knew she walked around like this all the time then maybe, but this is an Urgent Care, not a Cardiology practice. Like it or not, Urgent Care is an exercise in liability mitigation and this lady was a liability. Link to comment Share on other sites More sharing options...
medic25 Posted February 20, 2019 Share Posted February 20, 2019 I would highly recommend that folks in Urgent Care and Primary Care read over the ACEP position statement on asymptomatic hypertension in the ED to get a sense of how we address this vital sign finding. We get at least one of these a week sent in by the local UC, drug store with a BP machine or PCP on-call coverage; punted to us when the patient has no complaints. It's always a fun conversation when the person sending them makes them think they are minutes from their head exploding and we say that there is nothing that we need to do... Even if you still plan on punting to the ED, you can at least dial back the expectation that we'll be "emergently" lowering their blood pressure. Link to comment Share on other sites More sharing options...
sas5814 Posted February 20, 2019 Share Posted February 20, 2019 Our policy is pretty strait forward. No end organ damage, no concerning symptoms, no ER. Call your primary care provider. It always amuses me when they decide to go to the ER anyway and basically get sent home with the same advice. Link to comment Share on other sites More sharing options...
Cideous Posted February 20, 2019 Share Posted February 20, 2019 We were recently sent a directive by our national medical director addressing this exact scenerio. Two patients with similar symptoms listed by the OP were sent home from our UC's last year and died. Sounds like they crucified the PA's that sent them home. Something about being a diabetic masking the pain associated with current end organ damage and our inability to do blood work on site. So they get to write a lawsuit explanation now....for the rest of their careers...... I would of sent her. Link to comment Share on other sites More sharing options...
sas5814 Posted February 20, 2019 Share Posted February 20, 2019 That scenario is an outlier and very rare. I know we are all risk averse but we can't avoid all risk and policies that try to do that end up wasting a lot of time and money. Policies have to be evidence based. Here is the variable(s). Is this patient in the system and if so what labs are most recent and what do they show? How well controlled are they generally? You can always do a finger stick and check a urine for some more information and then exercise some judgement. I'm currently under the microscope for a miss that wasn't a miss.I can't elaborate because its still in the mill. It will probably be ok in the end but being in this position for the first time in 30 years is nerve wracking because you never know what a committee or board or risk management group may decide. It hasn't changed my practice habits. Link to comment Share on other sites More sharing options...
Wish1pa Posted February 20, 2019 Author Share Posted February 20, 2019 1 hour ago, Cideous said: We were recently sent a directive by our national medical director addressing this exact scenerio. Two patients with similar symptoms listed by the OP were sent home from our UC's last year and died. Sounds like they crucified the PA's that sent them home. Something about being a diabetic masking the pain associated with current end organ damage and our inability to do blood work on site. So they get to write a lawsuit explanation now....for the rest of their careers...... I would of sent her. I did try to send her. She wouldn’t go. She did sign AMA, the question was basically if the patient refuses ER do you still treat Link to comment Share on other sites More sharing options...
cbrsmurf Posted February 20, 2019 Share Posted February 20, 2019 21 hours ago, Cideous said: 62 y/o High liability Diabetic (uncontrolled) Higher liability 212/115? Seriously? In a diabetic? Just giving Clonidine and sending her home? LOL you guys have bigger nuts then me I guess just sending her home from an Urgent Care. You did see she was an uncontrolled diabetic and know what the definition of a hypertensive emergency is?....and 62? No way she doesn't at least get offered and documented an EMS denial AMA ride to the ED. If this was a patient you had seen many times and knew she walked around like this all the time then maybe, but this is an Urgent Care, not a Cardiology practice. Like it or not, Urgent Care is an exercise in liability mitigation and this lady was a liability. From what the original poster described, she would not be categorized as having a hypertensive emergency. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 21, 2019 Moderator Share Posted February 21, 2019 5 hours ago, cbrsmurf said: From what the original poster described, she would not be categorized as having a hypertensive emergency. agree- it is not the bp #, it is the sx. blurry vision, chest pain, sob, hematuria, worst h/a of life, focal neuro deficit, etc = go to ER. 220/130 and feels 100% fine, here is a 1 week refill, go see your dr tomorrow and eat less salt. bps like that don't get that way over night, they creep up over time. Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 21, 2019 Moderator Share Posted February 21, 2019 https://www.mdedge.com/clinicianreviews/article/79156/nephrology/management-hypertensive-urgency-and-emergency HTN urgency V Emergency Link to comment Share on other sites More sharing options...
Cideous Posted February 21, 2019 Share Posted February 21, 2019 I hear you guys, and knew I would get this kind of response on these boards. However I stand by my real world action recommendations. Because of the patient's age, comorbids masking the "pain" of current end organ damage (diabetic silent MI anyone?) and of course her bp reading. If she crashes and the provider who sent her home gets sued, which they will, an attorney will savage them under deposition. The evidence based medicine defense is great, right up to the point where shit goes bad. Then you stand around wondering why your malpractice ins company is settling on your behalf without your input. Because they look at this and say...holy crap, settle!!!! I try and teach young providers common sense medicine in addition to evidence based. We swim in a sea of liability every single day, do these young providers really need to poke the shark and see if it bites while taking that daily dip? My suggestion is....no. Having said that, I respect the purest views on this encounter that others make, even if I don't agree with them Link to comment Share on other sites More sharing options...
sas5814 Posted February 21, 2019 Share Posted February 21, 2019 At the end of the day whomever saw the patient has more information that anyone. Sometimes, for no reason I can explain, something tickles my lizard brain and I do something I might not normally do. I got into a big hubub with a pediatrician last year because I had a strep negative kid with 4+ tonsils and malodorous breath and I treated him anyway. I got a fairly polite "help me in my battle against inappropriate antibiotic use" email and when I answered him explaining why I did what I did and further explaining its something that might happen 1-2 x a year he lost his....stuff. I asked if I could have his cell so anytime 24/7 one of "his" patients came in I could call him... he said no. So I told him to kiss my ass. They are my patient when they are here. I waited weeks for the blowback but it never came. Link to comment Share on other sites More sharing options...
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