A 72 y/o/m with a history of hypertension presents to the ED.
A thread.
A thread.
The man had been instructed by his primary care physician to monitor his blood pressure at home in order to help titrate anti-hypertensive meds. When the numbers of his store-bought wrist cuff read “192/108,” the calling service instructed him to go to the ED.
“Just in case.”
“Just in case.”
The patient had no symptoms. On arrival to the ED, his BP was 190/110. The ED sought evidence of end-organ damage.
“Just in case.”
EKG was normal. CBC, CMP, Troponin, UA, and head CT were normal.
A d-dimer was normal, but a chest CTA was performed regardless.
“Just in case.”
“Just in case.”
EKG was normal. CBC, CMP, Troponin, UA, and head CT were normal.
A d-dimer was normal, but a chest CTA was performed regardless.
“Just in case.”
The emergency clinician opted to place the patient in the hospital’s observation unit, citing “hypertensive urgency.” S/he was challenged on this diagnosis by team members, however cited medicolegal fear in the decision for hospitalization.
“Just in case.”
“Just in case.”
The admitting clinician performed a history and physical that was similarly devoid of worrisome signs or symptoms, aside from mild erythema of the legs consistent with benign stasis dermatitis. Nonetheless, the patient was started on IV vancomycin for cellulitis.
“Just in case.”
“Just in case.”
Shortly after initiating vanco, the patient developed flushing about the face and neck as well as mild hypotension consistent with Red Man Syndrome, a non-allergic infusion reaction. The vanco was stopped, but the rapid response team administered IM epinephrine.
“Just in case.”
“Just in case.”
Administration of epi caused the patient’s blood pressure—predictably—to rise even further. He complained of mild chest discomfort, and a subsequent Troponin was mildly elevated, consistent with demand ischemia. The inpatient team consulted cardiology.
“Just in case.”
“Just in case.”
The consulting cardiologist recognized the relatively innocuous reason for the patient’s mild troponin elevation, however due to age and co-morbidities, recommended an echocardiogram. The study was technically limited and the patient was taken for angiography.
“Just in case.”
“Just in case.”
During the procedure, the patient was sedated. The cardiac cath revealed non-obstructive coronary disease.
Unfortunately, he suffered an aspiration event. At this time he was said to be upgraded to inpatient status. Abx were started for aspiration pneumonitis.
“Just in case.”
Unfortunately, he suffered an aspiration event. At this time he was said to be upgraded to inpatient status. Abx were started for aspiration pneumonitis.
“Just in case.”
Tragically, the patient deteriorated. Herculean efforts were made in an attempt to save his life, however the patient died four days after entering the emergency department.
His family was devastated, however understanding and comforted by the tireless efforts of the ICU team.
His family was devastated, however understanding and comforted by the tireless efforts of the ICU team.
The man was cremated and interred at a local Veterans’ cemetery.
Weeks later the patient’s widow received mail addressed to her late husband.
Inside was a bill for tens of thousands of dollars, charges incurred during her husband’s ED visit and “observation” that were not covered by Medicare or their supplementary plan.
Just.
In.
Case.
Inside was a bill for tens of thousands of dollars, charges incurred during her husband’s ED visit and “observation” that were not covered by Medicare or their supplementary plan.
Just.
In.
Case.
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