Friday, February 1, 2013

Three Dirty Words: Do You Remember...

The Gist:  There's more uncertainty in medicine than most of us would like, especially in emergency medicine.  We are often required to act with limited information and data and sometimes we make mistakes.  Good medical students and physicians reflect on these mistakes in order to improve.  EMCrit's Scott Weingart and Cliff Reid of Resus.Me demonstrate an excellent example of the benefit of reflecting upon cases with unfavorable outcomes in this podcast.

The case:  "I have a sick one for you, do you remember that woman y'all sent home on Tuesday..."  A sinking feeling crept over me as I glanced at the name on the "board," rushing to the room.

Two days prior: A 63 year old female with a history of diabetes came into the ED in the midst of influenza season with a two days of myalgias, subjective fever, dry cough, congestion, nausea, and vomiting.
  • VS: T 99.3F, P 90, R 18, BP 124/78
  • PE: The patient looked somewhat sick.  Nothing focal on physical exam. 
  • Significant Diagnostics: Chemistry and blood counts within normal limits, Glucose 155. CXR - normal
  • I sat down with the patient to discuss options for disposition - observation versus discharge.  After our talk, the patient stated she felt significantly better with the ondansetron and fluids and wanted to go home with an anti-emetic.  She and her significant other promised to return for worsening of symptoms. 
This visit: The same patient presented with the chief complaint, "I feel like I'm dying," after two syncopal episodes at home.
  • VS T 102F, P 160's, R 22 (actually closer to 30 upon visualization), BP 90/64
  • PE: Gen-Patient pale and diaphoretic, unable to stand under own power.  CV-Tachycardic. Resp-rhonchi in left lower lung. 
  • Significant Diagnostics: ECG-atrial fibrillation with rapid ventricular response, BMP - Cr 1.88, Glucose 160, WBC 13.1
This case filled me with a sense of unease.  I had been rather confident on the patient's initial presentation that she would improve at home.  Nasty bugs were going around the community and this patient visibly improved in the ED.  Instead, she developed sepsis and I felt apologetic.  I thought back to my thinking two days prior and searched for cognitive errors.  Premature closure and anchoring likely played a role in the case - all diagnostics were negative and the patient didn't even meet SIRS criteria.  I stopped searching based on lab reassurance, despite my gestalt (limited as it may be).  Furthermore, she promised me she would return if she felt worse - I felt betrayed.   

I was reminded of a grand rounds lecture delivered by University of Florida chief resident, Dr. Brandon Allen, entitled "Do You Remember?" in which he shared the following video (very much worth watching!).

Take Away:
  • Engage in shared decision making.  Empower patients to understand their medical situation, risks and benefits of interventions, and allow them make some decisions for themselves.  Understand that patients don't always do what we want them to do. Wyer et al state it succinctly in this article
    • "We should be careful about complacency when it comes to reversion to the paternalistic medical model of decisionmaking. An abundance of evidence attests to the fact that physicians’ decisions on behalf of their patients may be entirely contrary to the decisions the same physicians would make on their own behalf"
    • Inform the patient, in simple language, of their condition, any evidence that may aid them in making a decision (ex using PECARN: fewer than 1 in 2000 kids that have an injury like this would have something that needs be treated picked up on a scan).  Decision aids or instruments, many of which are found on MDcalc may be helpful (just phrase them in a way the patient can understand).
    • Document this process. 
  • Check for cognitive errors when working patients up, especially if the clinical picture doesn't correlate with the diagnostics.  
  • Learn something from each case and carry it forward in a productive fashion.  We're not perfect and predicting a patient's future is dangerous; however, discussions with peers and mentors about cases may add another perspective and enable one to hone clinical performance and thinking.  Alternatively, it may affirm your decision making and action.  
  • Beware of a reactionary response. 
    • An attending once told me that I should never send a patient with a DVT home without a CT scan of the chest to look for a PE.  The physician had a bad experience once and had adopted this practice which is really not the standard and potentially detrimental to many patients.  Clinical experiences can be surprising and terrifying.  I certainly have very limited experience, but I think that the cases that weigh on our minds have the potential to alter our clinical practice meaningfully which can be good or deleterious.  Beware of overcompensation.
Case Conclusion:
  • BP improved in the ED with 3L of IVF.  Patient spontaneously converted into normal sinus rhythm.  Patient treated for sepsis secondary to pneumonia, had a small troponin bump during the hospital course, but had improved and was discharged after a few days in the hospital.
  • I was very thankful that I had documented the shared decision making discussion and return precautions well.

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