Category: heuristic

Last week emcrit proposed that we have lost our nerve: that we fail to act when action is called for, that we tend to commit errors of omission, rather than errors of commission, and so we should toughen up, give ourselves permission to act, provide maximally aggressive care everywhere. A chorus responded with the obvious objection that we are doing way, way too much and that we are causing massive amounts of harm with overtesting, overdiagnosing, and overtreating.

I review hundreds of high-risk cases per month, and in patients who have bad outcomes, we do often conclude that the bad outcome could have been prevented by doing more. It really does seem as though there is a reluctance by non-surgeons to perform dangerous procedures, and that this reluctance often results in harm.

The easiest way to explain this discrepancy is that maximally aggressive care everywhere might be a reasonable paradigm if everywhere for you is a resuscitation bay (cue Casey).  But of course M.A.C.E., if interpreted as when in doubt, do more is an unreasonable paradigm even in the resus bay–we don’t want to do more, we want to do the right amount. Part of knowing the right amount is knowing medicine, and part of it is knowing yourself. Most of us tend toward overtesting and overtreating, but under-resuscitating (most of us but not all of us–we’ve all run into clinicians whose threshold to do dangerous procedures is too low, they are way scarier). This is why there is a lot of wisdom to contradictory rules of thumb like don’t just do something, stand there and if you’re not sure whether to intubate, intubate.

When you spend a lot of time reviewing cases, you start to think about the patient in front of you from the perspective of the person reviewing the chart next week; this mindset has spawned a useful cognitive strategy I call the preferred error. If you make the right choice, or the patient does well, fantastic. What matters is when you’re wrong, or there’s harm. So consider the consequences of being wrong on both sides of the decision, and determine which course of action fails better.

Looking at if you’re not sure whether to intubate, intubate from the future backward, its rationale becomes obvious. If you intubate a patient who doesn’t need to be intubated, how much harm is done? Some harm. And there’s the slight chance that you will fail to intubate and cause harm by trying, but this is quite unlikely. Now consider, what if you don’t intubate, but it turns out the patient needed to be intubated–how much harm is done? Potentially a lot of harm when that patients later requires a crash intubation, which is much more dangerous.

The preferred error considers how much harm if you’re wrong, but you must also consider how likely you are to be wrong, and factor that in. The hyperadrenergic patient–hypertensive, tachycardic, hyperthermic, agitated–has a differential filled with dangerous conditions, and it may take some time to sort out. You’re contemplating alcohol withdrawal, you think there’s a 30% chance that this is alcohol withdrawal. Should you treat for alcohol withdrawal? Consider what would happen if you treat with benzodiazepines, and he didn’t have alcohol withdrawal: not harmless, but probably minimal harm. And how likely is it that he doesn’t have alcohol withdrawal? About 70%, so 70% chance you might cause minimal harm. But what if you don’t treat with benzos, and the patient does turn out to have alcohol withdrawal? Very bad, lots of harm, the patient will get a lot sicker, might seize, might need a crash intubation. So 30% chance of causing a lot of harm if you don’t treat. Treat. Lots of tough decisions become easier when you consider the preferred error.

Lastly, when you’re still not sure what to do, you can hedge, and hedging means prepare. In the severe asthmatic you’re nervous about but you think you can turn around, but you’re not sure, and you really don’t want to intubate, but someone told you if you’re not sure whether to intubate, intubate, the way to manage that risk is get everything ready to intubate. Fully prepare, cognitively and materially, to intubate, as you throw every asthma therapy you’ve got at the patient. Preparation gives you the chance to be right, while minimizing the harm if you’re wrong. Preparation is the respect we pay to risk.

 

A common mistake made by junior emergency physicians (and sometimes not junior emergency physicians) is to identify a problem and address it without considering its precipitant. Recognizing that the patient’s symptoms are due to an exacerbation of CHF, asthma, or COPD, DKA, seizure (the med student thought it was syncope but you know better), atrial fibrillation, hypoglycemia, dehydration, hepatic encephalopathy, uremia, or electrolyte disturbance: that’s fabulous. Knowing how to treat these conditions: phenomenal. But if you really want to impress the opposite sex, or the same sex, or whatever you’re into, figure out why the patient is having this problem, now. Fortunately, the same things cause most of the common afflictions of ED patients. So here they are, the precipitants of everything:

 

medication changes and, especially, noncompliance

recreational intoxicants and other lifestyle choices

withdrawal (but why was this patient unable to get his fix today? there may be a further precipitant)

infection (lungs, urine, skin, CNS, abdomen, indwelling catheters and devices, soft tissue/bone)

ischemia (heart, brain, bowel)

arrhythmia

pulmonary embolism

thyrotoxicosis or hypothyroidism

occult trauma / abuse / neglect

bleeding (GI bleed, vaginal bleed, urologic bleed, retroperitoneal bleed, abdomen, thorax, thigh, street)

pregnancy (if there’s abdominal pain, bleeding, or syncope – don’t forget to rule out ectopic)

 

That doesn’t mean we ought to do ancillary testing to rule out these precipitants of everything; in most cases a directed history and physical is all you need. Just remember to ask the question, why is this patient having this problem, now?

 

 

{adapted from a lecture I give to first year med students, at the end of a two-week course where we teach them how to be an effective first responder in a variety of pre-hospital emergency scenarios.}

 

 

 

Emergency doctors staff emergency rooms. We see whatever comes in, as fast as it comes in. We are the front door of the hospital, and we never close our doors. The specialty is defined by several key characteristics, which are virtues or vices, depending on your perspective, and often they are both at the same time. So I’m going to present them as both at the same time, in a sort of pro-con format.

 

1. The undifferentiated patient

No other doctor routinely manages patients she knows nothing about. A typical emergency patient was found on the street in a coma. He could be minutes away from dying, or just really drunk and needs to sleep it off. We’ve got to figure it out without even knowing his name, much less his medical history or the events leading up to his present condition. Making the diagnosis is really fun.

However, Uncertainty is the currency of emergency medicine. We have to make important decisions with very little information. We are wrong a lot. Sometimes, when we’re wrong, people die. Learning to be comfortable with uncertainty is difficult.

 

2. Speed

Emergency physicians have to think fast and act fast.  It has been reported that emergency medicine has the highest decision density not just of any medical specialty but of any human endeavor. This is fantastic for people who have limited attention spans and require a lot of stimulation. It also makes shifts fly by; I routinely realize it’s time to start wrapping up and I feel like I just arrived.

However, when you work in the emergency room, you are working hard. It’s tiring.

 

3. Momentary care

Emergency physicians do not follow patients. When you’re off, you’re off. We do not carry pagers. Being off when you’re off is a big deal from a quality of life perspective – when your shift ends at six, and you make plans for eight, you’re going to be there, and you’re not going to get called away.

However, we don’t form relationships with patients, and the patients we do form relationships with are usually not the kind of patients you want to form relationships with. Emergency medicine can feel impersonal, and it’s harder to learn from your mistakes because the consequences of your mistakes often are not apparent until you’re no longer taking care of the patient. But mostly the problem is that we don’t get chocolates from our patients at holiday time.

 

4. Shiftwork

Scheduling for emergency docs is flexible – if I want a month off, I can just ask not to be put on the schedule for a month. Combine this flexibility with the momentary care aspect–that we don’t follow patients–and you can see how this makes for a kind of freedom that is pretty unique in medicine.

However, emergency clinicians work erratic hours, including nights. This is probably the biggest challenge for emerg docs. If you need a regular schedule to sleep right, this is not the speciality for you. The ED never closes, and so we work evenings, nights, weekends, and holidays. We take a lot of pride of being available whenever we are needed, but sometimes you can feel out of sync with the rest of the world.

 

5. The front door

We are the safety net for everyone and, health care reform aside, that’s not going to change anytime soon. The emergency department is on the ground floor, and when you work in the emergency department, you feel like you are connected to the community. You feel like you are helping people who really need help.

However, our workflow is dictated by whatever comes through the front doors, and this is entirely unpredictable. The emergency department is in a constant state of barely controlled chaos, and sometimes it’s uncontrolled chaos. Many of my patients are having the worst day of their lives. Many of my patients live on the margins of society and their average day is worse than the worst day of most people’s lives. It can be very challenging to take care of these patients.

 

6. Disease spectrum

You name it, we deal with it. No other specialty even comes close to the multiplicity of presentations and diagnoses that an emergency physician confronts in a single shift. You get to put your hand in a lot of cookie jars.

However, emergency physicians rely heavily on consultants. I spend a lot of time on the phone talking to people whom I’m giving work to, so they don’t really want to talk to me. Also, when I call a consultant, I’m talking to someone who knows more about what we’re talking about than I do. When I have a complex neurology problem, I call a neurologist and talk with her about neurology; when I have a complex dermatology problem, I call a dermatologist and speak with her about dermatology. And sometimes consultants can get really uppity and even condescending, especially the ones who never come down to the emergency department and see us reducing fractures, and defibrillating people in cardiac arrest, and delivering babies, and sewing up the laceration on the billionaire everyone’s heard of who’s lying one gurney over from the undocumented immigrant who also has a laceration and speaks a language no one’s heard of, and providing comfort care to the 96 year old taking her last few breaths, and intubating the nearly dead 10 day old with undiagnosed congenital heart disease. But constantly asking for help can be hard on the ego. You have to be comfortable not being the expert.

 

 

 

Terrific myth-busting letter to editor in this month’s Annals.

“…we retrospectively reviewed 104 consecutive cases of patients with insurance leaving against medical advice in 2008 from a suburban level I trauma center that sees 57,000 ED visits per year. Our review included 19 insurance companies, including HMOs, PPOs, Medicare, Medicaid, and workman’s compensation. We found that all 104 visits where the patient left against medical advice were fully reimbursed by their respective insurance company.”

Thank you, Wigder et al.

doi:10.1016/j.annemergmed.2009.11.024