How to Keep From Putting Your Blinders On

[usalsfyre]

As my H&P skills have become more refined, I find myself struggling to seriously consider other differentials seriously in the face of the likely issue. For instance, last night we were sent to a SNF for altered LOC. I walked in the door suspecting UTI. I got handed lab results that indicated UTI. The foley had frank sediment. I still performed some other diagnostic stuff, but never seriously considered other causes. When I realized this it started to bother me, as I feel like I'm setting myself up to miss subtle presentations. How do y'all keep the wider view?

 

[abckidsmom]

You walked into a tough situation, though. Resident of SNF? Age > 70? AMS is UTI or pneumonia until proven otherwise, right?

I'm currently reading The Gift of Fear, which puts a lot of emphasis on intuition. Your brain notices so much, way more details that you can consciously notice without having a routine that you go through. You went in with a suspicion based on knowledge and experience, and every detail you noticed confirmed, not denied that suspicion.

Imagine the same situation, where you went in and found the same thing: dispatched for AMS, at the nurses station you hear "UTI, AMS x 6 hours, foley with sediment, fever..." and then went into the room and found the patient to be a flaccid lump of a person, with gross pedal edema and a heart rate of 32. This would obviously get you thinking beyond the UTI, and quickly. And knowing what you do, you automatically would suspect that this is a dramatic change, because people who have been sick in bed for days don't really have hugely swollen feet, so he was likely up in a chair at some point today, which makes this a relatively new and dramatic change in his condition.

I'm willing to bet that you did a complete exam, knowing you to be an excellent clinician. So you heard nothing in his lungs (not pneumonia too...), what neuro exam you could get was at least symmetrical, pupils equal (not a CVA...), EKG normal (not an MI/cardiac issues), his sugar was normal (not hypoglycemia).

So you didn't strongly consider those issues, because they were extremely unlikely. But you "ruled out" those possibilities as reasonable suspicions.

Anyway. I'm arguing that a skilled clinician IS keeping the wider view, just more subconsciously than you realize.

 

[Tigger]

You walked into a tough situation, though. Resident of SNF? Age > 70? AMS is UTI or pneumonia until proven otherwise, right?

I'm currently reading The Gift of Fear, which puts a lot of emphasis on intuition. Your brain notices so much, way more details that you can consciously notice without having a routine that you go through. You went in with a suspicion based on knowledge and experience, and every detail you noticed confirmed, not denied that suspicion.

Imagine the same situation, where you went in and found the same thing: dispatched for AMS, at the nurses station you hear "UTI, AMS x 6 hours, foley with sediment, fever..." and then went into the room and found the patient to be a flaccid lump of a person, with gross pedal edema and a heart rate of 32. This would obviously get you thinking beyond the UTI, and quickly. And knowing what you do, you automatically would suspect that this is a dramatic change, because people who have been sick in bed for days don't really have hugely swollen feet, so he was likely up in a chair at some point today, which makes this a relatively new and dramatic change in his condition.

I'm willing to bet that you did a complete exam, knowing you to be an excellent clinician. So you heard nothing in his lungs (not pneumonia too...), what neuro exam you could get was at least symmetrical, pupils equal (not a CVA...), EKG normal (not an MI/cardiac issues), his sugar was normal (not hypoglycemia).

So you didn't strongly consider those issues, because they were extremely unlikely. But you "ruled out" those possibilities as reasonable suspicions.

Anyway. I'm arguing that a skilled clinician IS keeping the wider view, just more subconsciously than you realize.

Very well said. I suppose it's worth adding that even if you are properly assessing every patient, you still have to examine and attempt to correlate your findings. I see some providers that form their impression, assess the patient (thoroughly or otherwise), and then for whatever reason choose to discount certain results that do not support the initial impression.

As someone like yourself no doubt already knows, a cursory assessment is a waste and is only a vain attempt at substantiating guess work. To me if you're still assessing for other causes and you're listening to the results you get, all is well. It seems like that the House of God zebras quote is perhaps appropriate here. Not to mention it's quite clear that you have far more knowledge than the average medic and because of you knowledge of the subtitles of patient presentation, you have more to consider when you examine a patient.

 

[Veneficus]

Advice I was once given...

I was told once by my fire/arson investigation professor.

Always look at what you know.
Always ask yourself why you might be wrong.
Always consider there is something about the event you don't know.

I have found consciously reminding myself this advice on every patient helps a lot.

Another thing that helps me that I have to remind myself about, since a large part of my time is patient populations that do not fit into the "norms" or respond to "standard" treatments, is that whether an animal is a horse or a zebra depends largely on the point of view of where you work.

For example, in EMS, I have never seen a patient with what is sometimes considered the mythical "hypoxic drive".

But you don't have to spend more than a day in pulmonary to be convinced it is not a zebra.

From the same example, if you ask a pulmonologist what is causing the difficulty breathing in a COPD patient with CHF, they always seem to think it is the COPD. (otherwise the pt would be on the cardio ward right?)

However, I think we can agree from the EMS standpoint, you have to treat both in these patients, because one pathology plays off of the other.

Also nothing stops patients from having multiple (sometimes undiagnosed pathology)

Who is to say your septic UTI patient isn't having an MI or some other form of cardiac ischemia?

I have also learned the value of doing at least a regional, and more often, system by system exam on patients. The latter can be done really fast (around 3-5 minutes) if you have it well practiced.

 

[AnthonyM83]

I love trying to get all intellectual and go right for the cause...but in reality I have to balance myself out and still go through my checklist of exams. As much as I'd rather not work off memorized scripts, at times it really saves me.

He's altered, so I'm still going to do BGL and 12-Lead even though I pretty much know it's a UTI. Original problem could cause another problem, or two independent problems, or something totally different... I still check myself so the patient doesn't get screwed if I have a brain lapse.

 

[mycrofft]

Assess despite prejudice ("What are you putting on the EKG for, he has a UTI"), treat your findings, and don't spend a lot of time being Dr Bell (or Greg House) when what you have is ten ambulance minutes to the hospital.

It's not just an EMS problem. A friend went in for a prostate-ectomy, felt bad going home postop, and it turned out he had a MI while in the hospital, maybe intraoperatively.

 

[Melclin]

Very interesting post.

I've found myself struggling with a similar idea lately. The term "full assessment" comes up a lot in discussions at work. I've noticed the term floating around here as well.

Its doesn't sit well with me. Medicine is totally familiar with the idea that you can't do every test on every pt. Its absurdly expensive, puts the pt at risk of direct complications and adds extraneous information that can confuse the issue at hand and can lead to further inappropriate testing/treatment. We were essentially taught a standardised assessment process at uni that was never supposed to vary depending on the patient. It never sat well with me and it wasn't what clinicians were doing on the road. The model being taught at uni has thankfully changed. More targeted H&P is now fundamental to the first year of the degree. This reflects the fact that our assessments are more complex, growing from a more detailed understanding of disease processes and we that have more tools of assessment. I think every assessment has to be targeted in some way. Even with our longer transports, I simply don't have the time to ask every single question about every single thing..and what would be the point? There is only so much that is relevant to any given presentation.

But this adds challenges. Where is the balance between wasting time collecting useless information and being thorough? I find myself writing my case sheets thinking, oh I didn't do X and I didn't Y...well thats okay, what would be the point? Its clearly problem N. I came to the conclusion that it was problem N about 10 mins after meeting the pt. I worry that I am putting the blinkers on and that my working diagnosis isn't evolving as the pt's clinical course declares itself.

I would be interested to know what wisdom can be learnt from medicine on the topic of deciding what assessments are and aren't indicated. Is there a process by which that happens? Some model of decision making? Or is it totally dependant on the individual clinician?

 

[JPINFV]

Very interesting post.

I've found myself struggling with a similar idea lately. The term "full assessment" comes up a lot in discussions at work. I've noticed the term floating around here as well.

The question is, then, what is a "full assessment?" I agree that every test or exam technique can't and shouldn't be ran on every patient. However if I think it's muscular-skeletal is it too much to take a quick listen to the lungs and heart? What about a review of systems? That's just questions, which could lead down other paths.

I think that a "full assessment" might not be as much as you think it is.

 

[Ewok Jerky]

I have much less experience than many others here but:

I know I will be giving my report to a nurse or a MD, someone with much more medical knowledge than me. When I am done with my report, I say "i think thats thats it, do you have any questions?" I really like it when they don't have any.

When I'm doing my assessment I think about what kind of questions I might get asked when I get to where I'm going and use those to "expand" my assessment.

 

[Veneficus]

Very interesting post.

I've found myself struggling with a similar idea lately. The term "full assessment" comes up a lot in discussions at work. I've noticed the term floating around here as well.

Its doesn't sit well with me. Medicine is totally familiar with the idea that you can't do every test on every pt. Its absurdly expensive, puts the pt at risk of direct complications and adds extraneous information that can confuse the issue at hand and can lead to further inappropriate testing/treatment. We were essentially taught a standardised assessment process at uni that was never supposed to vary depending on the patient. It never sat well with me and it wasn't what clinicians were doing on the road. The model being taught at uni has thankfully changed. More targeted H&P is now fundamental to the first year of the degree. This reflects the fact that our assessments are more complex, growing from a more detailed understanding of disease processes and we that have more tools of assessment. I think every assessment has to be targeted in some way. Even with our longer transports, I simply don't have the time to ask every single question about every single thing..and what would be the point? There is only so much that is relevant to any given presentation.

But this adds challenges. Where is the balance between wasting time collecting useless information and being thorough? I find myself writing my case sheets thinking, oh I didn't do X and I didn't Y...well thats okay, what would be the point? Its clearly problem N. I came to the conclusion that it was problem N about 10 mins after meeting the pt. I worry that I am putting the blinkers on and that my working diagnosis isn't evolving as the pt's clinical course declares itself.

I would be interested to know what wisdom can be learnt from medicine on the topic of deciding what assessments are and aren't indicated. Is there a process by which that happens? Some model of decision making? Or is it totally dependant on the individual clinician?

From the practical point, when evaluating a local illness or injury, a quick check to make sure no obvious signs of systemic involement or other issue seems adequete.

 

[Akulahawk]

As to doing a standardized assessment process, I think that it's a good thing to learn. If you know nothing else about your patient, you'll have a process to follow. If you can interact with your patient, or as you learn what is going on with the patient, you can then begin doing more focused/targeted assessments.

I also like giving report and actually getting questions... specifically targeted ones because that means that they were listening, and that I've already answered most of their basic questions. If they have no questions for me, I wonder if they were listening to the report, made no sense to them, or simply disregarded everything I said because I'm "just" EMS.

 

[Tigger]

I have much less experience than many others here but:

I know I will be giving my report to a nurse or a MD, someone with much more medical knowledge than me. When I am done with my report, I say "i think thats thats it, do you have any questions?" I really like it when they don't have any.

When I'm doing my assessment I think about what kind of questions I might get asked when I get to where I'm going and use those to "expand" my assessment.

I am the opposite, I don't really like it when whoever gives gets my report doesn't have any questions. Half the time it's fairly easy to tell that the RN (it's fairly rare here to give a report to an MD unless its a floating med student) just flat isn't listening at all and only wants my run sheet with the vitals, PMH, and allergies. The rest of the time it seems like the staff couldn't give to two craps about what we think and just want us out, which I can respect to a degree, I get the ER is a busy place. I'd much rather be challenged as to why I made a certain point so I can get some education out of it. And yes, I get that it is not the random ER staff's job to educate me, but more often than not "no questions" equals "we're fine, please leave."

 

[Veneficus]

I am the opposite, I don't really like it when whoever gives gets my report doesn't have any questions. Half the time it's fairly easy to tell that the RN (it's fairly rare here to give a report to an MD unless its a floating med student) just flat isn't listening at all and only wants my run sheet with the vitals, PMH, and allergies. The rest of the time it seems like the staff couldn't give to two craps about what we think and just want us out, which I can respect to a degree, I get the ER is a busy place. I'd much rather be challenged as to why I made a certain point so I can get some education out of it. And yes, I get that it is not the random ER staff's job to educate me, but more often than not "no questions" equals "we're fine, please leave."

If it helps, I know a handful of physicians (all of them EMs) who intentionally never listen to EMS reports so they do not have any prejudgements in their exam.

One of them actually got burned when he put a stroke patient in a psych room because the pt had a history of psych. (I saw it in person and had to write a depostion for the hospital administration on it)

I have also discovered many providers passively listen for "magic" words when you give your report.

I don't agree with it, because I know EMS can provide nonmedical context that makes a difference in medical care. (like how they found the pt, where, living conditions, etc.) But it is a perspective to consider.

 

[JPINFV]

If it helps, I know a handful of physicians (all of them EMs) who intentionally never listen to EMS reports so they do not have any prejudgements in their exam.

The handful of times as an EMT I gave report to a physician pretty much all they wanted was where they were coming from and the C/C. If that's all they want, then it's no skin off my back.

 

[Ewok Jerky]

Yes I definitely agree with you guys about the questions/paying attention bit.

What i was thinking of was any questions that I hadnt already asked or forgot or didn't think of.

 

[abckidsmom]

Yes I definitely agree with you guys about the questions/paying attention bit.

What i was thinking of was any questions that I hadnt already asked or forgot or didn't think of.

Like it or not, the er staff are going to have to make some judgements about the EMS provider about whether they are trustworthy, believable, intelligent, etc. the only way we have to present that image is to look sharp (that is, neat and tidy, nothing else), give the most information possible with the fewest words possible, with very little umming and uhhhing.

When we present information in logical order giving the brief story with logical add ons, then waiting till the nurse is ready to write anything that needs to get written (meds, history, etc) they will either get all the information or know that they can get the info from the patient.

If I am getting report from someone who doesn't have it all together, I don't ask them for more details, I dismiss them. If I am getting report from someone who does have it all together, I know and might ask them for a couple of details, but really, that's about it.

My patient now, they get to be done.

 

[Akulahawk]

Like it or not, the er staff are going to have to make some judgements about the EMS provider about whether they are trustworthy, believable, intelligent, etc. the only way we have to present that image is to look sharp (that is, neat and tidy, nothing else), give the most information possible with the fewest words possible, with very little umming and uhhhing.

When we present information in logical order giving the brief story with logical add ons, then waiting till the nurse is ready to write anything that needs to get written (meds, history, etc) they will either get all the information or know that they can get the info from the patient.

If I am getting report from someone who doesn't have it all together, I don't ask them for more details, I dismiss them. If I am getting report from someone who does have it all together, I know and might ask them for a couple of details, but really, that's about it.

My patient now, they get to be done.

My point exactly. That's why I don't like not getting any further questions... When I get some questions, it's a signal to me that you 1) are listening and 2) need some additional details because you're in data collection mode. Once you feel you're ready to take over, then you can dismiss me and the patient is all yours!

 

[Aidey]

I don't agree with it, because I know EMS can provide nonmedical context that makes a difference in medical care. (like how they found the pt, where, living conditions, etc.) But it is a perspective to consider.

I've found the docs I work with fall into 3 categories. Those that actively seek us out, they are the ones who are usually in the pts room before we can get the gurney out of the way. Those that like to talk to us, but only if it is something interesting. And those that couldn't care less.

I've found the docs that meet us in the room are generally interested in if we did actual treatment* and the non medical context information. Especially if the pt is coming from a facility and isn't able to give much or any information.

The docs that like to talk to us, but only if it is something interesting seem to use as to further triage the patient. Depending on how busy things are it can take a while for the RN to update the doc. By talking to us they get basically the same info as the RN would give them, but faster.


*Actual treatment meaning actively treating the patient, not just starting an IV and transporting.

 

[abckidsmom]

And the tox guys always want to talk to us.

 

[Aidey]

tox guys?