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Protocol-Based Treatment of Hypertension: A Critical Step on the Pathway to Progress
Thomas R. Frieden, MD, MPH, Sallyann M. Coleman King, MD, MSc, Janet S. Wright, MD.
JAMA. 2014;311(1):21 doi:10.1001/jama.2013.282615
The undiagnosed and untreated incidence of Diabetes in this country far exceeds that of the rest of the modern World. If the article is to be believed half of us are walking around with BP in excess of 140/90. Are treatment protocols the solution to correcting this burden?
I think not. The problem is not treatment protocols or any treatment, but diagnosis of the hypertension in the first place. Judging by my experience with students, hospitals clinics and offices, the BP cuff is the most neglected and misused instrument in the clinic. The best you can hope for is a very expensive automated BP machine that may or may not be reliable, never mind calibrated. The operator of the auto BP machine likely has minimal training in its use and little or none in the anatomy, physiology and principal of BP readings.
The only reliable BPs readings come from the physician him or herself, the least likely person to waste time on such a mundane thing as vital signs, and even then a cavalier attitude can negate abnormal findings. A good RN will get you good BPs if you give her a good cuff and a mercury manometer, but there too, administrators do not want to waste RN time taking vital signs when it can be done at the lowest cost denominator by an assistant. If a number gets duly recorded. that satisfies the administrator and any auditor that might review the chart.
Can you say why, for instance, you might want to take the BP in both arms or at least in the right arm? Was the patient standing, sitting or recumbent when the reading was taken? Was the cuff the right size; was the stethoscope turned the right way, or was one earpiece of the stethoscope behind the ear of the assistant, or did she bother to take the patient's sweater off?
If any of us, psychiatrists included, profess to practice by the Hippocratic method -- by that I mean total focus on the patient observing every detail -- then the physician must surely examine the pulse, the appearance and the blood pressure. I submit that if half of us are running around with undiagnosed hypertension or pre-hypertension, then half or more of the BP recordings in the patient record are wrong. How long does it take to take a BP and note the patient's pulse? How often do you suppose the assistant fails to note an arrhythmia? There are BP machines outside almost every pharmacy. I have yet to try one that I found believable. The point is that diagnosis of HT will emerge as epidemic if we bother to sit down with our patient, look them in the eye -- not the computer -- and take the pulse and BP ourselves. (Left arm BP may be normal in Coarctation while the Right arm and cerebral circulation reaches high levels.) Protocols are worthless in the absence of the right diagnosis.|
Thomas R. Frieden, MD, MPH, Sallyann M. Coleman King, MD, MSc, Janet S. Wright, MD.
JAMA. 2014;311(1):21 doi:10.1001/jama.2013.282615
The undiagnosed and untreated incidence of Diabetes in this country far exceeds that of the rest of the modern World. If the article is to be believed half of us are walking around with BP in excess of 140/90. Are treatment protocols the solution to correcting this burden?
I think not. The problem is not treatment protocols or any treatment, but diagnosis of the hypertension in the first place. Judging by my experience with students, hospitals clinics and offices, the BP cuff is the most neglected and misused instrument in the clinic. The best you can hope for is a very expensive automated BP machine that may or may not be reliable, never mind calibrated. The operator of the auto BP machine likely has minimal training in its use and little or none in the anatomy, physiology and principal of BP readings.
The only reliable BPs readings come from the physician him or herself, the least likely person to waste time on such a mundane thing as vital signs, and even then a cavalier attitude can negate abnormal findings. A good RN will get you good BPs if you give her a good cuff and a mercury manometer, but there too, administrators do not want to waste RN time taking vital signs when it can be done at the lowest cost denominator by an assistant. If a number gets duly recorded. that satisfies the administrator and any auditor that might review the chart.
Can you say why, for instance, you might want to take the BP in both arms or at least in the right arm? Was the patient standing, sitting or recumbent when the reading was taken? Was the cuff the right size; was the stethoscope turned the right way, or was one earpiece of the stethoscope behind the ear of the assistant, or did she bother to take the patient's sweater off?
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