Straining the Strain Diagnosis

In this case, a woman in her late 30s was brought to the emergency department (ED) following a motor vehicle collision. She was a passenger in a car that was T-boned on the passenger side. Her principal complaint was neck pain. After plain radiographs showed no bony injury, she was discharged with cervical strain. She presented again to the same ED on three further occasions before her correct diagnosis was made. Aspects of implicit bias are highlighted in her care.

Overdosing the Overdosed

In this case, a middle-aged male presents to the emergency department (ED) of a general hospital with dizziness and weakness and a history of falling the previous day associated with seizures. There is also a possibility of head injury. He is well known to the department and has been seen previously by the head of the department regarding inappropriate use of the ED. Some difficulty ensues in terms of whether he has been having seizures or not, which, combined with a medication error and a laboratory error, results in him being overdosed with a significantly toxic drug. The case is an example of groupthink as well as fundamental attribution error.

A Rake’s Progress

This case discusses a middle-aged male who experiences abdominal pain and loss of consciousness at a mall. His wife believes he is having a heart attack and rushes him to a nearby emergency department. He is also experiencing some left shoulder pain and diaphoresis, which is misinterpreted at triage. This communication error leads to him being misassigned to a cardiac area. Eventually, the correct diagnosis is made, and the patient makes an uneventful recovery.

Pseudodiagnosis of Pseudoseizure

In this case, a 35-year-old male is brought to a community hospital emergency department by ambulance having suffered an apparent seizure in the street. He is well known to the nurses and physician who see him. He has had several visits for seizures, and he has a history of depression. He has had electroencephalography studies and a computed tomography scan of his head in the past and has had assessments by both neurology and psychiatry. While he is in the department, he has an atypical seizure. There is a consensus among the ED staff that his seizures may be factitious. After a period of observation, he is discharged. Approximately 6 months later, the physician hears that the patient has died and tracks down his autopsy report, which had a surprising finding.

A Model Pilot

In this case, a 43-year-old male presents to the emergency department complaining of blurred vision during the past few days. He appears apprehensive. His eye examination is completely normal. On the basis of his increased respiratory rate and apprehension, a diagnosis of anxiety state is made, and he is discharged home. He returns the next day with continuing symptoms. On this occasion, an arterial blood gas is ordered, which eventually reveals his correct diagnosis.

Teenage Tachypnea

This case involves a young woman sent from a psychiatric hospital to the emergency department for assessment. Her chief complaint is intermittent shortness of breath. According to the psychiatrist’s note, she has experienced frequent episodes of uncontrollable hyperventilation, associated with carpopedal spasm and loss of consciousness in the past. There is concern she may have a chest infection. A chest X-ray appears to exclude a chest infection as an explanation of her symptoms, and arrangements are made to transfer her back to the psychiatric facility with a diagnosis of exacerbation of anxiety state. Unexpectedly, there is a sudden deterioration in the patient’s condition, which proves fatal.

Introduction

Medical error is one of the leading causes of death, and most of these errors appear to occur in the ways that practitioners’ thoughts and feelings impact their decision making. Major gains have been made in the cognitive sciences in the past few decades that have provided a model for understanding how decisions are made—dual process theory. It is an excellent platform on which to examine the different ways decisions are made. Importantly, it allows for the examination of the pervasive influence of cognitive and affective biases on clinical decision making. Current medical training appears to fall short of what is needed to produce rational decision makers, due to what has been referred to as a mindware gap. Practitioners need to move from routine expertise to a higher level of expertise that will close this gap. A clear difficulty lies in finding ways of understanding and teaching the clinical decision-making process that do not violate the ecological characteristics of real-time clinical practice. By preserving as much as possible the rich clinical detail that makes up clinical medicine, this book attempts to offer important insights into the process.

Notable Near Miss

In this case, a 70-year-old female presents to the emergency department (ED) of a community hospital with facial swelling and rash. She was seen at her family doctor’s office 4 days earlier, when she was diagnosed with herpes zoster and started on medication. She complains of headache, blurred vision, severe pain in her scalp, and swelling around her eye. Attention is initially focused on her skin infection and the appropriate antibiotic treatment. She has two further visits to the same ED before a complication of her infection is noted, requiring referral for ophthalmological assessment.

Alternate Alternatives

In this case, an elderly female presents to the emergency department with a complaint of low back pain for the past few months. She has been receiving treatment from a chiropractor for misalignment of her spine but believes she is not improving. She is seen by an emergency physician, who finds an essentially normal exam. Specifically, she has no neurological findings and a completely normal musculoskeletal exam. Urinalysis shows clear signs of a urinary tract infection. She is started on an antibiotic, and at follow-up her back pain has resolved and her urinalysis is normal. The case provides an opportunity to review complementary and alternative medicine and its pitfalls.

A Tale of Two Cycles

Two cases are presented here, both involving traumatic injuries resulting from cycle accidents. Significant X-ray findings are missed by the emergency physicians (EPs) but picked up by radiologists in both cases. These are good demonstrations of the common search satisficing error. The first case also demonstrates a significant interference from factors that tend to push decision making into Type 1 processing—cognitive loading, fatigue, and dysphoria. The second case is an example of error due to the EPs’ routine being disrupted by a corridor consultation and authority gradient effects.