Misdiagnosis in the ED

[jmj11]

I heard this story on several news outlets today. I guess my questions for those who work in the ED, is this true? Is it excess (or typical for all areas of medicine) and if it is true, what seems to be the cause?

[EMEDPA]

I saw that. They are talking about single digit percentage points here. I am sure cardiologists miss 6% of atypical MIs too. There is a great doc who lectures on the EM circuit named Billy Mallon who talks about getting the right diagnosis as a dartboard. Big circles towards the outside are common things presenting commonly(wheezing in asthma). Everyone should get these. Slightly closer to the center are common things presenting atypically (asthma without wheezing or only with exercise). With some thought everyone should get these. As we get closer to the center we have common presentations of atypical/rare problems( sob and hemoptysis with PE in a cancer pt). A good provider should not ever miss these. Someone new or inexperienced might. The bullseye is uncommon things presenting uncommonly. If anyone catches these they are either really good or really lucky. The case he presented to illustrate this was a lady presenting with 6 weeks of pinky pain ,which turned out to be an MI. She had a nl exam and ekg, but was noted to sweat when the pain got bad. They checked enzymes and they were sky high and she got cathed. 95%+ of people would miss that, even if they noticed the diaphoresis.

That is a long way of saying things will always get missed sometimes in every specialty. This is not news. This is like one of those studies that says we checked with 1000 children and most like chocolate.

[ohiovolffemtp]

What Emed said: the unusual presentation of uncommon conditions is most easily missed, especially in the context of a busy ED.  If the patient's symptoms are non-specific, vitals stable, 1st level work-up un-remarkable, and the provider more concerned about the many patients that haven't even been assessed yet, there isn't the time to do the 1st principles reasoning to dig down to expand the differential to the faintly striped zebras and create and execute a more involved workup.  There's more likely badness in the waiting room that hasn't been identified.

[ohiovolffemtp]

Here's a link from Medpage to a review that's very critical of the methodology of the government report on which the NY Times article was based:

https://www.medpagetoday.com/opinion/faustfiles/102307?xid=nl_mpt_DHE_2022-12-19&eun=g1462813d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily Headlines Evening 2022-12-19&utm_term=NL_Daily_DHE_dual-gmail-definition

 

[CAdamsPAC]

On 12/16/2022 at 4:42 PM, jmj11 said:

I heard this story on several news outlets today. I guess my questions for those who work in the ED, is this true? Is it excess (or typical for all areas of medicine) and if it is true, what seems to be the cause?

My former S/P who was triple boarded (IM, Endocrine, EM) always said " when you hear hoofbeats, think horses not zebras". Hindsight in many things is 20/20.

[EMEDPA]

12 hours ago, CAdamsPAC said:

My former S/P who was triple boarded (IM, Endocrine, EM) always said " when you hear hoofbeats, think horses not zebras". Hindsight in many things is 20/20.

Yup. The more people know, the more they question. I worked with a doc with 5 boards(FP, IM, pulm, EM, anes).

Smart guy, but he still consulted all the time because he new his limits. 

[CAdamsPAC]

1 hour ago, EMEDPA said:

Yup. The more people know, the more they question. I worked with a doc with 5 boards(FP, IM, pulm, EM, anes).

Smart guy, but he still consulted all the time because he new his limits. 

New grads & PA students hear my mantra of there is nothing wrong with saying that you don't know and asking for help. I let them know they will be remembered longer for screwing up than asking for help.

[Boatswain2PA]

Terribly done "study" that didn't have a single datapoint from the US, but the hysterical media latched onto the inappropriate generalization of it to American EDs, thus resulting in their outrageous numbers.

No, no reality in all to it.

[ChrisPAinED]

On 12/16/2022 at 4:42 PM, jmj11 said:

I heard this story on several news outlets today. I guess my questions for those who work in the ED, is this true? Is it excess (or typical for all areas of medicine) and if it is true, what seems to be the cause?

Okay there is some truth but not completely. Some factors to keep in mind are patient presentation, providers level of competence, and general environment of care.  Unusual case presentations happen like patient describing new onset acid reflux normal ECG no other symptoms normal troponin because it just started easy to miss diagnose a NSTEMI with that presentation. Also some others examples like pt presents while there is a waiting room full your doing rapid triage on a chest pain you miss a little ST depression and vitals normal vitals and labs discharged a possible myocardial infarction while it was still early to make room for more sick patients. Last example patient with recent COVID diagnosis about 1/2 a week ago with worsening sob and check vitals then discharge with PCP follow up. Those examples included, unusual presentations, a little incompetence plus high stress environment, and last just incompetence.

 

Now most these are preventable patients heart burn just started now try something like "magic mouthwash" and if it doesn't approve trend the troponin one more time in 4 hours order a CT chest and abdomen and figure something out. Slow down when interpreting important findings the whole aspect of triage is finding the critical ones slow down and don't send them home. And Gosh dang it patient has worsening sob with say recent COVID check a CXR do a exam there could be more to it or a more invasion treatment needed. So yes it happens sometimes but a lot of providers are able to avoid the critical ones going home. (That was really long so I apologize) 

 

[EMEDPA]

43 minutes ago, ChrisPAinED said:

Now most these are preventable patients heart burn just started now try something like "magic mouthwash" and if it doesn't improve trend the troponin one more time in 4 hours order a CT chest and abdomen and figure something out. 

 

Be careful of this thinking. 15% of pts with cath proven cardiac chest pain claim relief from GI cocktails. If I use them at all it is at the end of the ED visit, not the beginning. I am more likely to use them in a young, otherwise healthy patient with a great story like a 25 yr old male with dyspepsia right after eating at taco bell, not a 75 yr old who got chest pain during dinner. 

[ChrisPAinED]

23 minutes ago, EMEDPA said:

Be careful of this thinking. 15% of pts with cath proven cardiac chest pain claim relief from GI cocktails. If I use them at all it is at the end of the ED visit, not the beginning. I am more likely to use them in a young, otherwise healthy patient with a great story like a 25 yr old male with dyspepsia right after eating at taco bell, not a 75 yr old who got chest pain during dinner. 

Well I meant after a thorough assessment that was coming clean and the history does change things like I would be admitting a sickly older gentleman if they developed chest pain and I couldn't figure why. Altho I didn't know that about the cardiac chest pain relief with the gi cocktails so thanks for the info