Two Handoffs with Different Outcomes

My 66 year old professional athletic patient had a history of a scar tissue related small bowel obstruction seven years ago related to a previous appendectomy. He now had similar symptoms with cramping, lower abdominal pain, and some nausea. Since his office was next door to his longtime friend and gastroenterologist he called over there. He was given an appointment with the junior partner since his buddy was out of town. Thirty years earlier I had referred him to that practice. The junior partner examined him, thought it was a self-limited viral illness and sent him home. The next day the two met in the Emergency Department for similar symptoms and once again the patient was sent home. The symptoms continued for 48 hours, and at the end of one of his long workdays he again saw the junior partner. This time the gastroenterologist sent him over to the hospital for a CT scan at about 6PM. Two hours later he received a phone call that the patient had a small bowel obstruction and the radiologist inquired of the GI specialist; “What should I do with him?” He was told to send him to the Emergency Department. When the physician in the ED called the GI doctor for admitting orders, he responded,” call his PCP (primary care physician) I am a consultant and I do not admit patients. “Forty five minutes later I received a call from the emergency department informing me for the first time of my patient’s problem and asking me to come in and admit the patient to the hospital. I asked him why the GI doctor was not taking ownership of the problem. I was told that the gastroenterologist said he was a specialist and did consulting not admissions. When I called the gastroenterologist directly I reached one of the covering partners who told me, “We are only gastroenterologists and we have not kept up our certification in internal medicine so we are really not qualified to admit a patient with a bowel obstruction or provide the day to day medical care.”

Another patient, 67 Hispanic and female was being treated for depression. She was under the care of a psychiatrist and in the middle of a medication adjustment. Her husband brought her to me because she was hallucinating, talking to her deceased father, acting violent and sexually inappropriate. I called her psychiatrist and then her neurologist who both answered the phone call immediately and suggested we schedule a CT scan of the brain. It showed a large brain frontal lobe tumor with much swelling around it and a hint of hemorrhage. I met with the patient and informed her of the problem and called the local university medical center to speak to the director of their brain tumor department. The university center is traditionally difficult to communicate with and receive information from. This time the young new department chair took my phone call, reviewed the clinical scans and data sent to him by fax and said, “She seems like she needs our help. If she can come down now I will have our team meet her and begin her evaluation. Later that night she clinically deteriorated. I text messaged the surgeon. He responded within minutes and said, “Send her down now; my team will meet her in the Emergency Department. “ I received daily clinical updates from this department chairman and prior to discharge he called me with a complete review, medication list, things to look for and emergency contact numbers if the patient had a problem. The professionalism, thoroughness and collegial communication was outstanding and far safer for the patient than for my local patient with a bowel obstruction. I was treated as a professional colleague asking for help with a patient rather than a generalist medical doctor expected to whatever the procedural specialist did not want to do.

I thought the gastroenterologist was both rude and dismissive of primary care physicians. I believe he abandoned his patient and created a safety issue by not calling me directly if he wanted me to assume the patient’s care. I was so upset that I brought the matter to the attention of the Chairperson of the hospital department of medicine and the associate chair of our medical executive committee. Both told me that similar things had happened to them. One told me of a nephrologist performing dialysis on a mutual patient who sent a patient unannounced to the Emergency Department because his vascular access was amiss and never called him about it but expected him to admit the patient and obtain appropriate specialty help to deal with the infection. The other doctor told of a cardiology patient who saw a cardiologist in an office that was across the street from the hospital. The patient was in dire straits with florid pulmonary edema and great distress so he sent him by ambulance to the Emergency Department. When he got there and the Emergency Department called him he said, “I don’t admit. Call his PCP for that.” He never called the patient’s PCP either to tell him he was sending this mutual patient who was critically ill to the hospital. Both medical staff officers told me that I could not hope to change a national culture which dumps on the PCPs and the patients. They told me it was not a hospital staff problem but one I needed to solve with the individual consulting groups.

Failure to communicate and take responsibility for care you have begun especially when the problem is in your area of expertise is a safety issue. It will come back to harm a patient someday. When these same gentlemen are sitting in court testifying in that medical malpractice case they will say the system is not fair rather than recognize that their inactions contributed to the problem. Hospital administrators and hospital boards using physicians they now employ and a limited number of local private physicians they can control have created a culture of poor communication between caregivers at a time when the technology exists to make communication far simpler and easy. They choose physicians for committee positions that are easy to influence. Community and public input into the policies of local hospitals and health care delivery systems has been eliminated or limited so that the driving force for policy is profits whether you are dealing with a for profit or nonprofit facility. In this setting the probability of errors occurring and patients’ being harmed because of lack of communication is greatly increased. There is institutional indifference to this problem and the safety organizations responsible for inspecting hospitals have not addressed it yet.

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SPRINT Study Supports More Aggressive Blood Pressure Targets

For several years now there has been a growing controversy over how low to lower blood pressure to reduce health risks. The most recent recommendations were to lower systolic BP to 140 or lower in men and women less than 60 years old, with a higher systolic blood pressure of 150 in those over 60 years older. There has been much recent concern that if we lower systolic blood pressure too much in senior citizens we fail to perfuse the brain with needed blood supply carrying oxygen and nutrients. The end result is a clinical appearance of dementia or cognitive impairment. Researchers recognize that to achieve a systolic blood pressure of less than 140 most patients need to take at least two blood pressure pills. There has been a great deal of difficulty convincing patients to consistently take those two blood pressure pills so the thought of adding a third medication to achieve a systolic BP of 120 or less is quite challenging.

To answer the question of how low to optimally lower blood pressure, the National Heart and Lung Institute instituted the SPRINT study looking at 9300 men and women over age 50 that had high blood pressure. One group was attempting to lower systolic blood pressure to 120 or less. The other to 140 or less. The study was scheduled to run through 2016 and conclude in 2017. The goal was to see if the lower blood pressure reduced the number of heart attacks and strokes. Last week the Federal government announced that the reduction in heart attacks and strokes in the aggressively treated group was so pronounced that they were stopping the study early. With the lower systolic BP the heart attack and stroke risk was reduced by nearly a third and the death risk by 25%. To achieve the desired systolic blood pressure of 120 or less required the daily use of three distinct blood pressure medications per patient.

In the process of cutting the study short to announce the results for the public’s benefit, the researchers were not able to answer the question of whether senior citizens would suffer more falls from getting dizzy with the lower pressure or if the lower pressure resulted in more cognitive impairment and dementia due to hypoperfusion of the brain. The only question they answered is that a lower target blood pressure will result in less death due to heart attacks and strokes. They did not address the issue of whether lower blood pressures would result in less chronic kidney disease either.

There are many academic researchers who hail the SPRINT study as cutting edge in further reducing cardiovascular injury and death. Other researchers are peeved at the failure to look at the effects on dizziness, falls, dementia like symptoms and kidney function with the lower blood pressure in our elderly population. As a practicing clinician I will look at each patient situation individually. I will suggest maximizing lifestyle issues such as smoking cessation, weight reduction, lipid control and sensible exercise before adding additional medications to lower blood pressure even more. We will recognize that many of you are already on two blood pressure medicines, an antiplatelet agent, a lipid lowering agent plus other medications before we add a third class of blood pressure medicine to get your systolic blood pressure even lower. With the side effect profile of most blood pressure medications including electrolyte imbalances, fatigue, effects on frequency of urination and sexual function, we must consider the individual pros and cons of further lowering BP by additional medication very carefully.