The email version of this case asked for other examples of critically ill two-fers:
I once saw a two-fer in the emergency department "fast track" during the peak of COVID, both of whom had a known COVID exposure & COVID-like symptoms, but one of whom mentioned urinary frequency as an associated symptom. An astute RN had the patient give a urine sample before I examined them, and because it was at the bedside, I happened to send it for analysis. UA notable for large amounts of glucose and ketones - further workup noted pH 6.9 (and in that context, I identified Kussmaul respirations that I initially attributed to COVID). COVID + new-onset DM in DKA, admitted to ICU. Had the urine not been sitting at the bedside, I think between triage bias & confirmation bias I would have sent the COVID test, clinically treated for viral symptoms, and discharged home. Eternally grateful that a proactive RN helped me not miss this case!
Attributing symptoms to anxiety or panic attacks is fraught in any setting. IMO it's dangerous and irresponsible. I never once gave my UC colleagues grief for turfing patients to the ED-they shouldn't be expected to manage sick people (and we shouldn't insist that they do).
I killed a patient in my first year out of training. Diagnosed/treated pneumonia when it was in fact a PE/pulmonary infarct. Fortunately the family did not sue. That miss stayed with me for the entirety of my career.
Implicit bias may have been a component leading to a missed diagnosis. The case mentions patient was obese, had learning difficulties. She may have had difficulties expressing herself. This can be frustrating for physicians who are pushed to see x number of patients during the shift. Implicit bias is kick in. Where are the safeguards to protect those putting their licenses, their livelihoods, credibility, and sanity at risk everyday?
This was a PE until proven otherwise. I would have bolused her with heparin before the labs or CT. This is a lay down and take it case. Sorry that happened!!!
Pretty awful case. I don't bolus heparin until I have objective evidence of a PE because I've been burned enough times on cases where it literally seemed like a textbook PE and it wasn't, and I've also covered enough cases where overly aggressive anticoagulation killed people.
Fortunately I've never had an adverse reaction to initial heparinization based on clinical gestalt - short half life, no initial drip until thrombus diagnosed, etc. Litigation's primarily based on outcomes, right? If a poor outcome, the rationale' is 'hey, I did all that could do at the time...'. I worked most of my career in Wayne County during the malpractice wind-falls of the 90's and 2000's...nightmarish! Appreciate your newsletter!
UC is risky because of the discharge mindset like you said and the other PPE (production pressure error). This was a bad miss. Yes, anxiety can cause tachypnea and tachycardia, but not usually this much. And anxiety doesn't cause desaturation no matter how anxious the patient is.
This case is giving me flashbacks! Early in my career I missed a PE in a mother daughter two fer with almost the same story. Fortunately there was no bad outcome. I use it as a teaching example of biases to avoid in emergency medicine.
How would having a family member with medical training increase likelihood of a bad outcome? I’ve found being female significantly increases being diagnosed with anxiety or constipation when in fact it was a ruptured appendix.
I don't believe that's the message the writer was trying to share. I think the message was that pts with bad outcomes with family members that are in the medical field lead to LAWSUIT. People with or without family members in the medical field have just as much risk of ending up in the wrong hands. The difference is when a family member can identify that their loved one received care that was not standard. This is what increased the lawsuits.
I think there's another unfortunate reality that adds to the list of why such a miss occurred: extremely obese female patient (and I'm also going to guess, not white) leading to bias that the patient's signs and symptoms are just their being morbidly obese and "overly dramatic."
I was actually a defense expert in a malpractice case involving a "two-fer" - husband and wife. They also went to an urgent care, and both had influenza. Unfortunately, husband had influenza related ARDS in 24 hours and eventually died. Wife had a minor illness, and recovered uneventfully.
The other issue with #4 is that it can, sometimes, increase the risk of a counter-productive interpersonal dynamic between the family member and the doctor/provider. If the family member makes their presence known in a bit of a challenging or assertive way, and if the doctor is a tad intimidated or just feeling a touch contentious, the dynamic generates psychological resistance and thinking that can get rigid. Given that a good conversation is one of the best diagnostic tools we have, a tainted dynamic can increase the likelihood of a misdiagnosis.
Totally agree. I prefer when family members tell me they're medical, it helps me know how to explain things. But I know it can cause some angst at times.
Hubris? Time Pressure? Lack of experience? Physician ability to rule out serious disease based on history, exam and clinical judgement is not as strong as we were taught. There’s a reason why emergency medicine specialists order so many tests, use evidence based decision tools, have low thresholds to admit patients. Sometimes Defensive Medicine is actually Smart Medicine.
Depending on the scenario, it often seems that the history and exam themselves are simply poor quality tests, even in the hands of the most skilled clinicians.
I understand Depo-estradiol would increase VTE risk because of estrogen, and obviously another missed red flag in this case. Relatedly, dose Depo-provera increase risk as well? I've read that progesterone does not increase VTE risk, but I've never seen an explicit statement saying Depo-provera is NOT a VTE risk factor.
There was a meta analysis from BMJ in 2012 that did not find increased risk with progestin only contraceptives. Seems like there is some mixed data but really nothing that demonstrates a definite link even with many large studies. And I suspect when many people talk about it they actually mistakenly think it is combined.
The email version of this case asked for other examples of critically ill two-fers:
I once saw a two-fer in the emergency department "fast track" during the peak of COVID, both of whom had a known COVID exposure & COVID-like symptoms, but one of whom mentioned urinary frequency as an associated symptom. An astute RN had the patient give a urine sample before I examined them, and because it was at the bedside, I happened to send it for analysis. UA notable for large amounts of glucose and ketones - further workup noted pH 6.9 (and in that context, I identified Kussmaul respirations that I initially attributed to COVID). COVID + new-onset DM in DKA, admitted to ICU. Had the urine not been sitting at the bedside, I think between triage bias & confirmation bias I would have sent the COVID test, clinically treated for viral symptoms, and discharged home. Eternally grateful that a proactive RN helped me not miss this case!
Great catch
😳
Thanks for sharing! The 2-fer emergency is rare but definitely lurking.
Great example of the holes in the swiss cheese *not* lining up and stopping a critical error with patient harm.
Attributing symptoms to anxiety or panic attacks is fraught in any setting. IMO it's dangerous and irresponsible. I never once gave my UC colleagues grief for turfing patients to the ED-they shouldn't be expected to manage sick people (and we shouldn't insist that they do).
I killed a patient in my first year out of training. Diagnosed/treated pneumonia when it was in fact a PE/pulmonary infarct. Fortunately the family did not sue. That miss stayed with me for the entirety of my career.
I know of several cases like that. Very tough to deal with for everyone involved.
Implicit bias may have been a component leading to a missed diagnosis. The case mentions patient was obese, had learning difficulties. She may have had difficulties expressing herself. This can be frustrating for physicians who are pushed to see x number of patients during the shift. Implicit bias is kick in. Where are the safeguards to protect those putting their licenses, their livelihoods, credibility, and sanity at risk everyday?
This was a PE until proven otherwise. I would have bolused her with heparin before the labs or CT. This is a lay down and take it case. Sorry that happened!!!
Pretty awful case. I don't bolus heparin until I have objective evidence of a PE because I've been burned enough times on cases where it literally seemed like a textbook PE and it wasn't, and I've also covered enough cases where overly aggressive anticoagulation killed people.
Fortunately I've never had an adverse reaction to initial heparinization based on clinical gestalt - short half life, no initial drip until thrombus diagnosed, etc. Litigation's primarily based on outcomes, right? If a poor outcome, the rationale' is 'hey, I did all that could do at the time...'. I worked most of my career in Wayne County during the malpractice wind-falls of the 90's and 2000's...nightmarish! Appreciate your newsletter!
Tough environment! Thanks for reading my newsletter and for commenting!
I highly recommend reading Kahneman's "Noise" 978-0-00-830899-5
Post facto, we are all very smart. This is a sign of inexperience. And an amateur.
This work is hard.
I read Thinking Fast/Slow but havent read Noise, will have to check it out!
I think also a mindset of UC=Not Sick. too many times focused on moving meat rather than actually taking care of patients.
Point 4 is very true
UC is risky because of the discharge mindset like you said and the other PPE (production pressure error). This was a bad miss. Yes, anxiety can cause tachypnea and tachycardia, but not usually this much. And anxiety doesn't cause desaturation no matter how anxious the patient is.
I like to think that I would have caught this based on vitals but the 2fer thing is terrifying……note to self
This case is giving me flashbacks! Early in my career I missed a PE in a mother daughter two fer with almost the same story. Fortunately there was no bad outcome. I use it as a teaching example of biases to avoid in emergency medicine.
Eerily similar, I'm grateful you got to learn the lesson without a bad outcome!
How would having a family member with medical training increase likelihood of a bad outcome? I’ve found being female significantly increases being diagnosed with anxiety or constipation when in fact it was a ruptured appendix.
I think the writer is saying that there is an increased chance of the bad outcome leading to a lawsuit.
I got that. But what are his guesses as to why that is happening?
People without medical training may lack the skills or knowledge to recognize when their loved one has been poorly mismanaged.
I don't understand, because his #4 point is that family members WITH medical training are more likely to have bad outcomes.
The operative words here are “LEADING” and “LAWSUIT”
Someone with some sort of medical knowledge are more likely to criticize the actions of a physician thus leading to a lawsuit.
I don't believe that's the message the writer was trying to share. I think the message was that pts with bad outcomes with family members that are in the medical field lead to LAWSUIT. People with or without family members in the medical field have just as much risk of ending up in the wrong hands. The difference is when a family member can identify that their loved one received care that was not standard. This is what increased the lawsuits.
Thank you for explaining! That's exactly what I wanted to understand.
I think there's another unfortunate reality that adds to the list of why such a miss occurred: extremely obese female patient (and I'm also going to guess, not white) leading to bias that the patient's signs and symptoms are just their being morbidly obese and "overly dramatic."
"overly dramatic" "histrionic" "very anxious" yah because being on the brink of death is going to make you feel very, very anxious indeed.
I was actually a defense expert in a malpractice case involving a "two-fer" - husband and wife. They also went to an urgent care, and both had influenza. Unfortunately, husband had influenza related ARDS in 24 hours and eventually died. Wife had a minor illness, and recovered uneventfully.
Wow! Out of curiosity, did the decision to (or not to) prescribe Tamiflu play much of a role in the lawsuit?
I'm guessing (hoping?) there's a lot more to the story than you're revealing...?
The other issue with #4 is that it can, sometimes, increase the risk of a counter-productive interpersonal dynamic between the family member and the doctor/provider. If the family member makes their presence known in a bit of a challenging or assertive way, and if the doctor is a tad intimidated or just feeling a touch contentious, the dynamic generates psychological resistance and thinking that can get rigid. Given that a good conversation is one of the best diagnostic tools we have, a tainted dynamic can increase the likelihood of a misdiagnosis.
Totally agree. I prefer when family members tell me they're medical, it helps me know how to explain things. But I know it can cause some angst at times.
Hubris? Time Pressure? Lack of experience? Physician ability to rule out serious disease based on history, exam and clinical judgement is not as strong as we were taught. There’s a reason why emergency medicine specialists order so many tests, use evidence based decision tools, have low thresholds to admit patients. Sometimes Defensive Medicine is actually Smart Medicine.
Depending on the scenario, it often seems that the history and exam themselves are simply poor quality tests, even in the hands of the most skilled clinicians.
I understand Depo-estradiol would increase VTE risk because of estrogen, and obviously another missed red flag in this case. Relatedly, dose Depo-provera increase risk as well? I've read that progesterone does not increase VTE risk, but I've never seen an explicit statement saying Depo-provera is NOT a VTE risk factor.
There was a meta analysis from BMJ in 2012 that did not find increased risk with progestin only contraceptives. Seems like there is some mixed data but really nothing that demonstrates a definite link even with many large studies. And I suspect when many people talk about it they actually mistakenly think it is combined.
Incredible miss - amazing no workup was completed with those vitals