Bernie's situation is an example of why those walk-in clinics aren't the best solution

[pnwmom]

for many.

After he fell in the shower and needed stitches, even though he has excellent insurance he went to a walk-in clinic. At his age and after an accident like that, he should have had a full examination, including for potential heart problems. But a walk-in clinic isn't set up for that.

If he had had such an examination, they might have detected the blockage last February and inserted a stent or stents then -- better than walking around for months, at risk of a heart attack.

This could have been so much worse -- for example, if he was on a cross-country flight when he was having his symptoms. Fortunately he was in a situation where he could quickly get good care.

Campaigning is grueling. I hope all the other candidates had full physicals before they started on this path, and are taking good care of themselves.

[OnDoutside]

1. Surely he should have been referred by his own doctor ?

[pnwmom]

2. Only if he went to his own doctor and asked for a referral. But if he had had a physical

back then, and in view of his shower fall, it's hard to imagine a scan wouldn't have shown at least the beginnings of a blockage (since it was big enough to require two stents).

[OnDoutside]

3. So they don't send a report to his own doctor ? That's not good.

[pnwmom]

5. I don't know if there's some standard protocol. When I've had to get medical care out of state,

I'm not aware of anything going back to my doctor at home, but that doesn't mean it didn't happen.

I think the likelihood is he didn't have a full physical after his fall because if he had it would have shown at least the beginnings of the serious blockage.

[TidalWave46]

13. I had to specifically request the information from my walk in clinic visit...

Be sent to my primary care doctor. I don’t know what normal procedure is but I think having to request it is fine. But I make the request with all doctors I see.

[OnDoutside]

23. Where I am, they always ask for your doctor's details and send on

a report of the visit. It makes sense to keep all the medical records with him.

[Blue_true]

15. Maybe some of the present or retired Doctors can weigh in.

Would a blood-pressure check or in-office EKG give indications that something was wrong?

[NurseJackie]

4. I feel like this is the end of his campaign.

After he fell in the shower and needed stitches, even though he has excellent insurance he went to a walk-in clinic.

That was definitely a lapse in good judgement. That was a decision being made by someone (Bernie? Jane? A staffer?) who cared MORE about "how-it-would-look" if BS went to the hospital, than about his ACTUAL HEALTH!

The symptoms of afib include dizziness, loss of balance, confusion, weakness ... and that's because the irregular and competing rhythms of the heart valves cannot get enough blood to the brain.

Even though stents are a common and routine procedure, that is by no means an indicator that it's a simple "outpatient" procedure (as some have wrongly suggested). It's INVASIVE and there's a GOOD REASON that things like this are done in HOSPITALS.

Campaigning is grueling. I hope all the other candidates had full physicals before they started on this path, and are taking good care of themselves.

Yes it is... and I believe this is the end of the road (campaign-wise) for BS. Even though he may end up living to be 100, the seeds of doubt have already been planted in the minds of many voters who are now wondering if he's healthy enough for the rigors of being POTUS and Leader of the Free World.

All I'm saying is that the voters are well within reason to be wondering and asking such things. I think the BS campaign's lack of information... being secretive, cagey... changing stories, etc etc... well, that just adds to the suspicion that people will naturally have.

[Blue_true]

16. You are a retired Nurse. Do you think his shower fall was more?

Like he actually fainted instead of slipped? Could the fainting have been an indicator of more serious problems like Flu or worse?

The only time that I have ever fainted was when I ran up several stairs a couple hours after donating blood. Live and learn, literally.

[NurseJackie]

20. You're right. The Mayo Clinic describes A-fib symptoms as including...

You're right. The Mayo Clinic describes A-fib symptoms as including the following. Looking at this list, it seems highly likely that his "slip and fall" could have been very likely precipitated by any of these things.

There's much more to this than the public is being told, I fear.

https://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/symptoms-causes/syc-20350624

Symptoms

Some people with atrial fibrillation have no symptoms and are unaware of their condition until it's discovered during a physical examination. Those who do have atrial fibrillation symptoms may experience signs and symptoms such as:

• Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat or a flip-flopping in your chest
• Weakness
• Reduced ability to exercise
• Fatigue
• Lightheadedness
• Dizziness
• Shortness of breath
• Chest pain

[Docreed2003]

6. A question I've been wondering about

Does his insurance cover for out of state procedures and interventions? Usually out of state care is incredibly expensive, not that he had a choice under these circumstances.

[vsrazdem]

8. I would think Bernie would be on Medicare probably with a Medigap policy.

[mopinko]

14. medigaps are sometimes state specific.

mine is.

medicare covers you anywhere in the u.s., but not foreign countries.

[elias7]

7. Respectfully disagree with the premise

The key to uncovering an underlying problem such as coronary disease is all in the history taking. A good physician, whether they be in a walk-in clinic, a primary care office or emergency department, would seek to understand the circumstances that resulted in a fall in the first place. The physical exam will not pick up evidence of coronary disease in someone who is asymptomatic. Further, a "scan" as mentioned in another post would not pick up coronary disease as CAT scans are not how coronary disease is diagnosed
Emergency setting. Regardless of the extent of potential blockages, coronary disease is picked up because of symptomatology. If the patient is having symptoms, a calcium score CAT scan could be done to assess risk, but this is not performed in an urgent care, out of the PCP office, or emergency department.

If Bernie lost his balance and fell, he may have just lost his balance and fallen. This happens to 80-year-old people. However, 80-year-old people often try to minimize symptoms such as preceding lightheadedness, palpitations, chest pain or shortness of breath. A good clinician seeks clues in any elderly person falling to determine if there may have an underlying cardiac or neurologic problem. A full physical exam does not generally pick up underlying coronary disease if the patient has not had a heart attack or is not having symptoms. There has to be a suspicion by history to do an EKG or place patient on a monitor to see if there are any cardiac irregularities.

With coronary disease, people are generally asymptomatic until they are not. If one starts to develop exertional shortness of breath or chest pain, a clinician will generally order a stress test unless symptoms are so clearly coronary in nature, a cardiologist may recommend going straight to a cardiac catheterization. Bernie may have been exhibiting some exertional shortness of breath or may have had a cardiac rhythm disturbance that could have caused transient unsteadiness, but if he just fell because of loss of balance, I doubt any physical exam could pick up potential coronary disease in an asymptomatic patient. It is all in the history.

[vsrazdem]

10. I agree. Even if he had gone to the ER for his head laceration, they would not have likely found it.

They could have possibly done a Head CT but that would not show anything related to his heart and even if
they did an EKG, it might not have shown anything at the time. Most of these cases are found because of symptons of chest pain, shortness of breath, headaches, dizziness, slurred speech, confusion, possibly caused by arterial issues. A head injury would not have been a reason to run these type of tests.

[pnwmom]

12. A good ER would refer him to a cardiac specialist to make sure there wasn't a serious reason

for the dizziness or fainting that caused him to bang his head.

[vsrazdem]

17. I though he said he hit his head on the edge of the shower door getting out, I didn't hear anything

about him being dizzy of fainting.

[pnwmom]

19. Logically, that makes no sense. And it is a doctor's job to think of the most likely possibilities,

one of them was that he was momentarily dizzy.

[vsrazdem]

21. I don't know why not, it makes sense to me. My dad one time walked right into a plate glass window

at Mcdonalds at night because he thought it was an open area. I have scraped my shoulder on the shower door getting out of the shower. I don't think there was anythiing nefarious about him hitting his head on the shower door.

[pnwmom]

22. Scraping a shoulder is very different than bashing a FACE and requiring 7 stitches.

We don't have eyes in our shoulders.

And the metal edged door should have been visible, in daylight, right in front of his face. It wouldn't be like walking into a plate glass window in the dark.

[elias7]

30. Well, I work in a good ER and we see elderly people falling all the time

As I said before, picking up on clues for underlying cardiac disease is on the history taking. We are very thorough in trying to talk with patient and family regarding circumstances surrounding falls including lightheadedness, dizziness, chest pain, etc. Sometimes people just bang their heads and sometimes people just slip and fall as balance can be an issue with the elderly.

I don’t mean to be pushing back on you so hard, but as an ER physician, I do not have an indication to refer every elderly patient with a fall to a cardiologist.

[pnwmom]

11. When a 78 year old has a full physical exam after a fall like that,

I think a good doctor would recommend a follow up with a cardiac specialist to make sure there wasn't an underlying cause to the fainting.

So that's what I was talking about -- as a patient, I think of a "full physical" as including the follow-up referrals that a good physician would then recommend. It appears this didn't happen with Bernie, or else he just ignored any referrals he got.

[elias7]

31. A full physical will generally not pick up developing coronary blockages

If you can help me with this, I would be grateful to learn what physical findings I might find as a physician that will give me a clue to someone having underlying coronary disease that is thus far asymptomatic. Most elderly patients have heart murmurs and some PVC/PACs or other minor cardiac rhythm disturbance. This is not a symptom of a coronary problem though.

The key is in being very diligent and patient and asking what kind of symptoms someone is experiencing and if there has been a change from their baseline. So, if Bernie had been experiencing periodic chest pains in stressful or active conditions, exertional shortness of breath out of proportion to the level of exertion, unexplained lightheadedness, etc., that would prompt further work up. Barring that, however, there is no indication to refer to a cardiologist as part of a good ER workup for a fall.

[kstewart33]

9. A simple EKG would have identified the problem.

Ten minutes, inexpensive, done in a doctor's office.

More men from their 60s on, should have one every year.

[Blue_true]

18. I got one on my last physical. Yes, it was fast.

The nurse put some conducting goo an my chest that put an electrode over each goo spot. The procedure took only about 10 minutes, like you pointed out.

[kstewart33]

24. And you're okay? nt

[Blue_true]

26. Yes. My parents had a history of heart and blood vessel issues.

Due to that history, an EKG is part of my annual checkup. I am extremely healthy, but a person never knows when that may change. I have been lucky enough to have had competent and thorough Doctors over my life so far (didn't have healthcare as a kid outside of emergencies, my parents could not remotely afford it).

[elias7]

33. Untrue.

Unless a person is experiencing active symptoms of angina, their EKG will be unchanged from their baseline. Most people with heart attacks, have acute EKG changes different from their baseline. If the patient is not having symptoms, an ECG will not tell you there is underlying coronary disease.

A routine EKG from time to time is reasonable to see if there has been a change from baseline. Most commonly, however, our EKGs do change as we age. Most changes will be a reflection of an underlying process such as hypertensive heart disease or some other chronic condition but not generally reflecting a coronary blockage until the patient actually does have a heart attack. Interestingly, most people with chest pains from angina do not have acute EKG changes.

It’s all in the story. If a patient has a good story suggesting symptoms due to coronary insufficiency, that is what will generally be the clue to investigate further. An EKG will tell if there is something happening in that moment, but generally little else. The physical exam generally tells you little unless someone is having an acute myocardial infarction. I have a little experience with this because I am an ED physician. We work up people for cardiac issues in perhaps 10 to 15% of our patients.

[Tom Rinaldo]

25. Walk-in clinics increase ACCESS to health care

In many instances they are more economically feasible to operate, in rural areas especially, than are full scale hospitals which may not be located near by. Walk-in clinics also are psychologically easier for many people to voluntarily utilize than are hospital emergency rooms. Too many people wave off seemingly minor physical ailments and symptoms rather than seek professional guidance. Ease of access lowers that avoidance threshold.

Knowing everything that I know, even as I type this, I will admit that were I to experience non alarming symptoms of a potential physical ailment I might well wait a day longer to go to a hospital emergence room than to a local walk in clinic. Of course, if I knew enough in the first place to realize that any discomfort I was feeling could possibly be a sign of some impending crisis, sure I would not hesitate to go to an emergency room. The problem of course is that I'm not a doctor, so what do I know?

A good doctor at a walk-in clinic should advice a patient when further testing is advisable.

[pnwmom]

27. I'm not really dissing clinics. We have used them for things like kids' ear infections.

But anyone who goes to one should realize the limitations. And if no one at the clinic told Bernie he needed more follow up after the shower incident, which was serious enough to require 7 stitches, they didn't do their job.

[Tom Rinaldo]

28. No argument with you on any of that n/t

[corbettkroehler]

29. Point Taken - The Shower Incident Should Have Raised A Flag

The correlation should not have slipped through. If he had Secret Service protection by this juncture, I suspect that his lead agent would have insisted he have it checked.

[BlueMississippi]

32. I'm sure the walk-in clinic gave him a referral to an internist or cardiologist

for further check-up. Not doing so would be malpractice.

I'm equally sure that BS ignored that referral, pooh-poohed it and went right back to campaigning.

There is no cure for patients who ignore doctors' advice.