On this past Friday night, I had the pleasure of transporting John to the U. John was already on my bad side when I showed up, as he called 911 at 0330, cancelled us while en route (less than five minutes later...), and then before we got back in quarters, called back again. Make a decision and commit man! Especially in the middle of a night!
So John was having 10/10 substernal chest pain. He was also having a headache, dizziness, nausea, blurred vision and difficulty breathing. Who can make the diagnosis...? Oh, by the way, his BP was 256/152. Got it now? Yea...
So we're getting vitals and working on a 12-lead when John says, "Why you doin' all that? I already been through all of this." You have? Hmmm... do tell sir.
Apparently John had similar symptoms twice already this week. He'd been twice to the ER this week. And twice, the ER prescribed and told him to take two anti-hypertensives. And now twice, John had not filled the prescriptions and had recurring symptoms.
I have two paths of ranting to go down about this. One at the patient, one at the system.
So my first instinct is to be angry at John. He's been told twice in one week what to do to keep his symptoms from returning. He doesn't follow instructions and guess what, his symptoms return. He agitated and thrashing around and yelling at me. And then indignant when I question about his understanding of the ER's diagnosis and prescribed treatment. "How would I know what they said is wrong?" Well John, I would think that would be one of the most important conversations to pay attention to. You have intolerable symptoms? You don't want to experience them again? I would think you'd be really interested in the cause of the problem and the attempted solution! Take some responsibility for your own health! Let's not even get to the fact that you're 33 years old, already have LVH and flipped T waves on your 12-lead and clearly uncontrolled hypertension. You'll be dead here soon if you don't get your disease under control, not just in pain and with uncomfortable symptoms.
So John, you can't afford your meds? To some extent I don't believe you. I believe you don't have much money. I believe you don't have insurance. But what I really believe is that your medications are the bottom rung of the priority totem pole. Because I see you have a cell phone. And that marijuana probably wasn't free. I know medications are less fun and don't assist your day to day social status like those things do. But they keep you from dying before the age of 40. And they keep you from waking me up in the middle of the night. Re-evaluate your priorities. Or maybe you'd rather die young, having fun. Have at it. Don't re-evaluate your priorities. But then don't scream about how no one is helping you. (By the way... that HCTZ the doc prescribed you? It costs about $6 for a two week supply. $6!)
And rant part two. The system. As everyone know by now, thanks to many articles written by more important people than me, in the American system of healthcare, the emergency departments are the catch-all. You show up to an ER with a complaint (bullshit or not), we have to see you, evaluate you and stabilize your condition. But theoretically, the ER doc who sees you will probably not see you again. Not really good for follow-up and management. Conditions like hypertension need to be managed long term. Otherwise, John is going to keep showing up in the ED with pressures of 250s/150s. And he'll stroke. And dissect his aorta. And have renal failure. Which will all involve hospital admissions and inpatient care. And way more money spent than if John had more definitive primary care. If we focused our time, effort and yes, money on making sure everyone had better access and follow-up with primary care, we would see fewer costly inpatient stays. And maybe, just maybe the ED could function as it was meant to. ED stands for Emergency Department. It does not stand for defacto primary care. Yet, that is most of what the ED does these days.
Ugh. Rant over.
-a
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