The legalities of a blood pressure

  1. We have a cardiologist who absolutely insists that it is impossible for a person to have a distolic blood pressure < 45 and still be alive. If he sees one written on the flowsheet he goes on a tirade about how much it's impossible and immediately writes orders for all BPs to be taken by hand (on our unit, the NIBP is taken by our Hewlett-Packard monitors). He also starts grilling nurses about what they would do if hauled into court to defend a blood pressure < 45.

    I can handle the tirade (he just looks like an idiot), and we've written a policy to have us take one blood pressure by hand q 4 hours if we get a NIBP < 45.

    My question is about his legal point. I know d**n well that a person can be alive with a diastolic that low (I've seen plenty). What can I say in response to his question, "How would you defend yourself in court?"
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  2. 14 Comments

  3. by   Furball
    weird,

    I see DBP less than 45 about once every 1-2 weeks.....does this Doc look at the MAP? If the pt isn't dizzy, is making urine, no s/s shock and the MAP is ok I just recheck it in an hour or 2. No tirades....
  4. by   hoolahan
    I've taken many BP's "by hand" and gotten diastolics <45! What is his point. This man is a cardiologist?? Hasn't he ever heard of aortic regurg?? It is not uncommon for there to be "no" diastolic, the beat keeps going until zero, and should be recorded from when the distolic muffles, down to when it is not heard at all, eg 140/36/0, if it continues down to zero.

    As to how I would defend myself in court, take out your Estes or Bates book on the correct procedure for taking BP, and cite articles on aortic regurg. I wouldn't even worry about defedning yourself in this way, there IS nothing to defend!! As you already know Matt. Sounds like this guy needs meds! We used to have a pediatric cardioligist who insisted that kids who were quite obviously having seizures, were NOT having seizures, they were just in a "state of agitated motion." Yes, this guy had to guy for psych counseling eventually, he was so nuts, he even scared administration!
  5. by   kewlnurse
    I would ask to see this MD's credentials, has he ever heard of an arterial line? I have seen plenty of DBP's <45, it's not that big of a deal, had a patient who's dbp was hangin in the 30's for a long time, no ionotropes needed. As far as court goes, bring in the documentation, ekg strips etc... that show all signs of live and make the person who is questioning you as well as the "expert" witnsee look like a fool since you can infact document a patient whos dbp was <45 and still alive and well.
  6. by   chowchow

    Wow, I've heard of some wild 'n weird stuff coming from physicians before; but, this one is unbelievable! I have seen many patients with DBP < 45, with a normal MAP, & asymptomatic. Also, I have experienced patients with DBP being heard all the way down to zero. We record it in the chart just like how Hooolahan stated. As far as defending yourself in court &/or to this Doc, I would research the topic at the library and bring the documented literature as my proof. Good Luck with Doc!
    Chowchow
  7. by   mattcastens
    This is purely hypothetical, but a question I want to bring up after reading some of your answers.

    Assume a doc wrote an order to maintain SBP>100. The SBP stays above 100 for several shifts, but because of diastolic BP, the MAP stays in the 50s. Pt. goes into renal failure a couple of days later and the family sues.

    Is the nurse liable for not notifying the doc of the low MAP even though the parameters were maintained? I would say yes.

    Any other thoughts?
  8. by   Brenna's Dad
    I would agree. Someone is liable for the man's renal failure.

    However, I'm trying to think of a BP where the SBP would be greater than 100 and the MAP at 50. Even if the SBP is 100 and the DBP is 40, the MAP is still 60. If the DBP is 30 and the SBP is 100, the MAP is still 53.

    I'm trying to remember if I have ever seen such a situation in my clinical practice, and I don't think I have. If an individuals DBP is that low, the SBP is low as well.

    But then again, the situation was hypthetical.
  9. by   hoolahan
    Wow Brenna's Dad, I didn't even analyze that MAP, just went with the question, but I guess you are right. You are a sharp one.

    However, let's assume for arguments sake, this has happened, then I agree 100% Matt, the nurse would be liable.
  10. by   VickyRN
    I have seen such a situation in my limited clinical cardiac experience. Wide variability in the pulse pressure (relatively low normal systolic, diastolic in 20's and 30's) can occur with disorders involving the aortic valve, namely aortic regurgitation. Also have noticed in such cases, if you take the blood pressure on the LEFT arm, it will be quite lower than the same on the RIGHT. I have always been told that it is the MAP that matters most--that as long as the MAP is 60 or above, the organs are being perfused. However, I have seen some patients who "live" with a MAP in the 50's.
  11. by   OC_An Khe
    In reply to the question, I would ask the Cardiologist the following. Could you please cite and provide to me the medical research that proves a patient can't be alive with a diastolic BP > 45.
  12. by   fedupnurse
    Apparently this "cardilogist" has never heard of aortic insufficiency? He'd probably be stupid enough to put an IABP in a patient like this! Tell The doc "If it were to get to court, I would explain the dynamics of aortic insufficiency and that the result is a low DBP. You usually have a murmur with that condition that can be heard at the nurses station even if the patient is all the way down the hall." I look at the flowsheet during report and if I see a low DBP, I go in to assess my patient expecting to hear a murmur.
    There are doctors like that in every hospital!
    fedupnurse
  13. by   ArenRN
    I would have my book opened at the section where it explains aortic insufficiency and have him read it as soon as he starts on the subject.
  14. by   kabarnes
    Are you sure he isn't referring to the MAP? While it is possible to be alive with a MAP of 45, that is quite low, however, I have seen diastolics below 45 before with a patient awake, alert and coherant.

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