High Blood Pressure Medication

There’s a joke about a woman whose blood pressure was 180/90.  She didn’t think she had reason to be concerned.  After all, she argued, 180/90 is the mathematical equivalent of 2/1 and that doesn’t seem so high, does it?

I once treated a young man of color, obese and sad looking, whose numbers were close to this – 170/100.  And I was not laughing.

This young man was schizophrenic for sure, but pretty harmless.  Life had beaten him down enough that his jail experiences — assault, as directed by disembodied “voices” — had him so frightened that he would never do anything the voices said. Not now, not ever, and I believed him.

As a psychiatric physician, I always managed to get “vital signs” on all patients.  That should not have been a battle, but it was. I did not understand nor relate to the medical assistants who took them.  Why?  18 months training after high school and they had not been nice to me — not at all — criticizing my lunch and the fact they did not think I worked hard enough.

I was concerned when I saw a blood pressure of 170/100.  Patient said he had been on some kind of medicine.  The best I could get with one of my “naming medicines and seeing what it sounded like” was hydrochlorothiazide — maybe. And of course the relevant parts of the chart were missing, as was the case more than actually finding anything.

He said he had stopped his medications a couple of days before because they gave

him a headache.  Stopping — or forgetting — blood pressure medication is a known and frequent cause of stroke.

I called the case manager for help and he told me to send the patient to the front desk.  Out of concern for the patient, I walked him to the front desk myself.  They sent me back to one of the medical bays.  Turns out, all available physicians had the day off.  I asked for a replacement and found a physician’s assistant – unsupervised — who told me to go to the front desk and get the patient an appointment the next day.

I introduced myself clearly as a psychiatric physician and said I was concerned about the patient’s blood pressure and the cessation of blood pressure medication.  I had been warned so many times about practicing outside of my specialty.  Any malpractice insurer would have agreed. I needed to take this patient to someone who actually prescribed the kind of medication the patient had stopped taking.

I had shown the blood pressure to the physician’s assistant, who told me that it was “not the worst I have ever seen.”  Wow, that was really helpful.

The physician’s assistant — who was standing there doing nothing — finally took the chart from my hands and asked the patient a lot of “sounds like” until he found a medication he was certain the patient had never had and the name of which he could not recognize.  He scribbled a prescription in the chart and sent the patient to the pharmacy, which I had to guide him to.

This clinic, of course, is a clinic for the indigent and homeless.  And unfortunately, the care I discuss was the rule rather than the exception.  Needless to say – I no longer work there.

This man could have easily stroked.  Actually, I am not certain that he has not stroked.

The quality of medical care has become a serious reason for national shame.  Nobody is perfect.  But most countries I can think of have much more going on than we do to help people.

We continue to debate access to care, while denying that quality can be — and indeed is — a serious issue.

I think of my first day of clinical classes at my medical school.  I think of the first lecturer, the head of the Department of Emergency Medicine, who stood up before the class and wrote a motto in Latin on the blackboard.  He then raised the blackboard for all to see.

He translated it for those who had not been taught Latin in high school.  Me, I had three years of it and I knew before he said it — “primum non nocere” meant “first do no harm.”

Maybe this childlike child of the street would have been better off without anti-hypertensive medication.  Maybe if he had not started them in the first place he would not have been subject to this dangerous rebound effect.  Maybe – sometimes — the medical care in this country is so bad that people are simply better off without any.

It doesn’t have to be like that.

My belief is simple.  Medical care can and will improve when people start to place the simplest of humanitarian worries above funding.