:: to the teeth ::    thoughts on social justice, medicine, race, hope and beats

"Another world is not only possible, she is on her way.
On a quiet day, I can hear her breathing." :: Arundhati Roy ::

"The most common way people give up their power is by thinking they don't have any." :: Alice Walker ::
Saturday, March 04, 2006  

Hypertension Crisis?

a 55yo gentleman came to the clinic yesterday. a smoker, he had known hypertension, untreated for 2 years from lack of funds and health insurance. he recently lost some vision in his right eye, a few weeks ago, which motivated him to find a doctor. he had the highest blood pressure i've yet seen in my career. 250/140. he was clear that he wouldn't go to the hospital, too expensive.

this raised ethical and legal questions for me. what is the right thing to do? he needs treatment, that is obvious, but where? in the clinic, in an ER, in a hospital setting? what does the research show? this is clearly a hypertensive urgency, perhaps even a hypertensive emergency (i would only know if i had more lab tools at my disposal). yet research is showing that if you drop the BP too fast, you place the patient at high risk of lots of complications, so outpatient treatment isn't necessarily wrong, it's just far from ideal. the benefit of the hospital is that you can monitor the patient, intervene immediately if he starts stroking or having a heart attack, you can monitor the blood for kidney function, etc. and all that costs thousands that this man doesn't have.

but what would a jury say if he stroked out overnight or had a heart attack? would they understand patient choice, system limitations, the role of a consulting doctor giving good information even if a bad outcome happened, the limitations of the patients resources? so many questions. would they understand that his high blood pressure is caused significantly by his own actions, smoking tobacco, taking in alot of caffeine? does any of that count? i believe it must so i will stand my ground, practicing medicine without mal-practice, even if it feels a little foolish now and then.

after counseling him on the importance of being in a hospital, i put him on norvasc 10mg daily and clonidine 0.1 mg three times a day, with a baby aspirin. i worried about this guy all night long. he was late to his clinic appointment today, making me more nervous. fortunately, he made it to the clinic, his BP was down to 200/135, he was feeling better, slept well, and is more committed to taking care of himself, now that he has an affordable option. he was still smoking though... i'll see him back on tuesday.


posted by andru | 3/04/2006 11:33:00 AM | |


very inspiring- it is gutsy to not have malpractice... trusting people and the universe made practical... a wonderful experiment

# posted by Anonymous Anonymous : 3/05/2006 3:50 PM  

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