A Country Doctor Writes:

It happened again the other morning.

As I left the conference area and crossed the main lobby I saw a young woman approaching the front desk, leaning on an older woman. I didn’t think much of it, and unlocked the clinic door. I did what I had to do, and as I returned to the lobby, I heard an overhead page “Triage at the front desk”. As I reentered the lobby, the young woman was on the floor and a lab tech was just leaning down over her. A medical assistant almost pushed her way through the door with me, emergency box in hand.

“What’s happening with you?” I asked the woman, who is my patient and has several chronic health problems.

“I need my blood pressure checked”, she answered.

“We’ll do that”, I said as we opened the box. “Why do you need your blood pressure checked?”

“I just need my blood pressure checked.”

“She passed out in the kitchen”, the older woman said.

“She’s a diabetic, check her blood sugar”, I said to the medical assistant as I placed the blood pressure cuff on the woman’s arm.

“Your blood pressure is fine”, I said. “Now, did you just pass out again?”

“160”, the medical assistant announced. Normal for a diabetic. Her pulse rate and oxygen saturation were also normal.

“I don’t think I passed out.”

“Do you hurt anywhere?”

“My behind is sore and my chest hurts.”

“She had chest pain this morning when she walked across the kitchen and fell to the floor”, said the older woman, who turned out to be her mother.

“Call the ambulance”, I called out.

“No, I want to go home”, the young woman mumbled.

“Listen, we don’t know why you passed out, and we don’t know yet what this chest pain is from. You need more testing.” I held my hand on her pulse for a while to make sure it was regular.

As the ambulance crew entered the lobby with their stretcher, she sat up and protested. The crew listened to my rapid fire description of her medical background and today’s events.

“You need to be checked out further”, one of the attendants pronounced.

They were in charge now, and I returned to my office and called the hospital to let them know what was coming.

Over the years I have seen countless patients who in a medical emergency have a specific idea of just what they need and whose medical care is delayed because of that.

When I first started practicing in this area, we didn’t have advanced EMTs on our volunteer ambulance corps. It was the on-call doctor’s duty to fill that role, which meant I would sometimes get paged after hours to meet the ambulance at somebody’s house or at one of the local motels.

Later, even when the ambulance service was upgraded, I would get calls from patients in the middle of the night, demanding that I open up the office, singlehanded, and do an EKG because the person figured that was the full extent of a medical assessment for chest pain. A few times my refusal to do so caused complaints to the management and the board of directors.

Ten years ago, we ended our longstanding free blood pressure checks. Until then, when we were titrating blood pressure medications, we would simply tell patients to drop in and have their blood pressure documented. We would then look over the numbers to make sure we got the medications right. But what started to happen more and more was that people who felt poorly and couldn’t get an appointment soon enough or were offered a time that was inconvenient for them would simply show up for a “free blood pressure check”.

Once in a room with the medical assistant, they would say, “I’m having chest pain”, or “I think I’m going to faint”, forcing the doctors to interrupt their schedules. Some patients event went so far as to threatening on the phone “if you can’t give me an appointment this morning, I’ll just come in for a blood pressure check and then you’ll have to see me”.

We are not the only practice that has to balance access with medical appropriateness. Most clinics and pharmacies, even Cityside Cardiology start their automated telephone attendant system with “If this is a medical emergency, please hang up and call 911…”

I’m grateful I’m not expected to meet the ambulance in the middle of the night or open up the office alone for someone who could collapse in front of me. I’m not complaining that people think we can do more than we are equipped to do. I am only puzzling about why, in this era of ever increasing sophistication in emergency care, so many people think they know exactly what they need.

Like the woman in the lobby – she had passed out and had chest pain, but her blood pressure was okay, so she wanted to go home.