When You're a Hammer, Everything Looks Like a Nail

Hypertension (HTN) in the ER is one of the least interesting things we deal with. Through many discussions with colleagues, this is a fairly universal sentiment among ER doctors. There are very few conditions in which we need to immediately lower a patient’s blood pressure. Aortic dissections, hypertensive emergencies, acute strokes, acute coronary syndrome, and preeclampsia are about the only ones that come to mind. These are referred to as “end-organ damage,” i.e., the HTN is actually causing an acute issue damaging the brain, heart, or kidneys, and it needs correcting.

Our tolerance for HTN is much higher than the average patient’s. HTN is very common, and patients often end up on 3–4 medications to keep it under control. Early in my career, this seemed strange to me as patients would come to the ER with HTN and tell me they were taking all of their medications as prescribed. Sometimes 4 or 5 different classes of medications—calcium channel blockers, beta blockers, ACEIs, ARBs, nitrates—and their BP was still 180/100.

I used to think patients were non-compliant with their medications; clearly, Big Medicine is correct, and if we’re throwing all that medication at patients, the problem must be the patient. But this didn’t really add up. I would talk to elderly females who are religious about taking their medications. They have pill boxes, set reminders, and do exactly what their doctor tells them to do. Sadly, they often don’t have much else to do besides focus on their medical problems. These are compliant patients, and yet, despite all that, their BP is still too high.

It wasn’t until later in my career that I learned about insulin resistance. I don’t recall this being taught in medical school in the early 2000s. But in 2026, insulin resistance and hyperinsulinemia are known to be drivers of HTN. So it’s not that patients were/are non-compliant; Big Medicine was and still is chasing the wrong thing. That topic deserves another post for another day.

Back to HTN in the ER… it’s boring. Us ER docs really don’t care. Most of us don’t get very excited about a systolic blood pressure south of 220–230. (Systolic is the top number.) However, patients seem to think that they will have a stroke or their head will explode if they reach a certain number. It’s true that having HTN is a risk factor for strokes, heart attacks, aortic dissections, and kidney failure. But there is no set number at which those things acutely happen. HTN is referred to as the “silent killer” because you can have it and not have ANY symptoms, and eventually, you will likely have complications because of it.

A colleague and I were discussing this recently, and their point was that long-standing HTN is like a movie. It takes time for the damage to accumulate, and we don’t know how the story ends. HTN in the ER is like watching 1 minute of the movie. That single point in time doesn’t tell me much of anything about how the story ends. One minute of HTN—i.e., the day you come to the ER worried about it—is not predictive of your long-term outcome. Ignoring HTN for months and years is a problem. HTN in my ER is not.

Which brings me back to the hammer analogy.

Patients have limited tools at home to diagnose themselves and troubleshoot what might be causing any number of symptoms. There are Apple Watches and the like, home BP cuffs, and home pulse oximeters to measure oxygen saturation. Checking your HR makes sense if you are known to have unusual heart rhythms. Checking your oxygen saturation matters if you have heart or lung problems that cause low oxygen saturations. A sustained HR that is too fast or too slow often indicates a problem. Sustained low oxygen saturations are also usually problematic. HTN is generally meaningless.

For example, a patient feels “off” or has some symptom they are concerned about. They check their BP, and it’s high. So what do they do? They check it again. They get anxious. It gets higher. They check it again. They get more anxious. It gets higher. They check it again. They get more anxious. It gets higher… And eventually they come to the ER or call 911. And yep, it’s often high.

But is the HTN related to their symptoms? Probably not.

I’ve seen patients connect HTN to pretty much any symptom: headache, nosebleeds, chest pain, shortness of breath, leg pain, arm pain, nausea, abdominal pain, back pain, neck pain, dizziness, palpitations, lightheadedness, “not feeling right,” feeling “off,” hearing my heart beat “in my ears”… the list is almost endless. You can have any of these symptoms AND HTN, but the HTN is rarely the problem.

If we were to monitor BP 24/7 on patients, it would fluctuate. Many of the symptoms above could be attributed to any number of things: stress (not measurable), anxiety (not provable), blood glucose highs and lows related to sugar/carb intake and the resulting insulin spike that chases your blood sugar down. Insulin resistance can be present months or even years before patients actually have prediabetes or diabetes.

We see plenty of patients who just happen to check their BP for no reason, or they are seen in a clinic or dental office with no symptoms whatsoever, and a paternalistic do-gooder insists they call 911. Nurse triage lines are notorious for scaring patients, and I’ve had patients tell me the nurse triage line threatened to call 911 for them when the patient didn’t even want to go to the ER and was just looking to make an appointment in clinic to discuss their HTN.

Patients from nursing homes, patients with a friend or family member with some tidbit of medical knowledge or an N-of-1 story about someone who had HTN and died. And yes, like I said, sometimes HTN really does need acute treatment, but it’s rare. Just because Uncle Bob had HTN and eventually had a stroke doesn’t mean every friend or relative of Uncle Bob needs the ER for HTN every time they think about it.

Convincing patients that HTN doesn’t matter for their time in the ER is often a lengthy discussion. If you don’t have end-organ damage, we don’t need to fix it. Official recommendations don’t endorse controlling HTN with IV medications in the ER apart from true emergencies. Patients need to play the long game and stay on their medications and follow up with primary care. (And in my opinion, control the insulin resistance with better eating, i.e., fewer carbs.)

There is also inconsistency among providers. The choices are often between a lengthy discussion with patients or just giving them some medication to make them feel better. You would think that we should all do exactly as the recommendations say, but that’s not reality. Patients can get outright hostile about what they think they need. I have been practicing talking to patients for >20 years, and most of the time, I do my best to take the time to explain all of this. Sometimes it’s friends or family members with the patient that insist we do something.

If I’ve made my best attempts to convince patients of what the recommendations are and I’ve addressed their concerns, some are still not satisfied. The risk/benefit ratio shifts. I have other patients to see. I risk patient complaints. I don’t have the time to keep having the same conversation 3 or 4 times as the interaction becomes more hostile.

We don’t do ourselves any favors when we don’t provide consistent care because patients may get treatment for their HTN when they don’t need it from one provider and the next time the provider doesn’t treat it. It sends mixed messages to the patient.

So, play the long game. Get your HTN under control with better eating and sometimes medications. But don’t check it just because you have a symptom.

Your home BP cuff is a hammer, but not everything is a nail.