These are both seemingly straightforward cases. Both trauma related issues and possible complications. It is easy to fall into the trap of trying to refer the patient on to someone else, to make it someone else’s problem.
But one of the distinguishing features of Emergency Medicine is that we get to solve puzzles and seek that which others may miss. Another salient characteristic required in EM is to be open-minded and adaptable. The undifferentiated patient is the norm, and an un-biased approach is key. Early biased labelling of patients can be detrimental to their health.
A doctor from othopaedics assesses patient 1 and says there is no obvious spinal level, and recommends that the patient should be reviewed by someone else.
By this time the ED has slowed down a bit and a new pair of eyes is cast upon the patient. He seems to be slightly tachypnoiec. A blood gas is done which reveals a severe metabolic acidosis, hyperkalaemia, and hyponatraemia. The hyperkalaeimia is refractory despite multiple potassium shifts. A U&E reveals acute kidney injury. This is possibly an adrenal insufficiency as well. He is transferred to another center for emergent dialysis.
Instead of Patient 2 being sent home, he is triaged and reviewed. He has photophobia and intermittent fever. He has severe neck stiffness, and a positive LP for meningitis.
In both these cases, life threatening medical conditions were masked behind the history of trauma. This lead to delays in diagnosis due to anchoring bias or misdirection.
Magicians use misdirection to prevent you from realizing the methods used to create a magical effect, thereby allowing you to experience an apparently impossible event. 2 
Most people are aware that this is the way in which magicians fool us into believing their magic tricks. It is often so easy and exciting to be drawn in by these masters of misdirection. In medicine, is it possible that we also often fall prey to similar misdirection in the form of cognitive bias?
The pitfalls of cognitive bias is a topic often highlighted in emergency medicine. When delving into the methods of misdirection used by magicians, there are two which we can easily fall prey to in the emergency department: distraction and attraction.
It is easy to become distracted when several things are happening at the same time. This is an everyday occurrence in the ED: the desire to “push the queue”; to make appropriate disposition plans for our patients; trying to listen and attend to students, other staff; multiple patients at once; thinking about that phone call that needs to be made; and trying to time that much-needed bathroom break. The list goes on and on. In an observational study conducted at two Swedish emergency departments, the interruption rate was 5.1 interruptions per hour4, which is about 1 interruption every 11 minutes. There are no studies quantifying the numbers in a busy South African ED. But from personal experience, the interruptions are often more frequent.
These two cases provided the reminder to be vigilant of cognitive biases in the ED. We need to be careful and attentive to the constant distractions and interruptions. We need to be mindful of fixating on only a specific portion of information. The individual who initially triages the patient may often not get the full history or relevant information. Just because a patient is triaged in a certain direction, does not mean they always belong there. This is one of the great aspects of emergency medicine; solving the puzzle and not being fooled by the magician.
Picture credit Lure. Nick Tackaberry. Flickr.com. Oct 2014
References
- A Mortal Battle with Four Hour Medicine. Johnston M. LITFL. Blog post updated May 2016
- A psychologically-based taxonomy of misdirection. Kuhn G, Caffaratti HA, Teszka R, Rensink RA. Front Psychol. 2014; 5: 1392
- Distraction. Merriam-Webster.com. June 2017
- Interruptions in emergency department work: an observational and interview study. Berg LN et al. BMJ Qual Saf. 2013; 22(8): 656-63
Interesting articles related to the subject
- From Mindless to Mindful Practice – Cognitive Bias and Clinical Decision Making Croskerry P. N Eng J Med. 2013; 368 (36):2445-2448
- Sonar Beams Deflecting Cognitive Error Stephen V. BadEM. blogpost July 2015
- Cognitive Decision Making and Medical Error. Sinclair D, Hicks C, Chartier L, Helman A. Emergency Medical Cases. Episode 11. blogpost Feb 2011
Blog post by Kylen Swartzberg @kylenswartzberg
Peer reviewed by @QuirkyMD
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