Clinical Grind 11 Not a Regular Headache

Post by Patricia Capone, OMS III

You’re a resident working a shift in a busy emergency department (ED) when you hear an EMS call come over the squawk box. Elderly female passed out at a local birthday party and is unresponsive on EMS arrival. Narcan was given and the patient woke up with an uncontrollable headache.

 

Initial thoughts:

  • Elderly patient + passing out = not good
  • Narcan seemed to wake the patient + Now alert and oriented = Triage appropriate?
  • Can you just watch and discharge?
  • Elderly patients use and can overdose on drugs too!

EMS was unable to get vitals because the patient is inconsolable and acting erratically. You hear her in the background of the call screaming, “My head, my head, something’s wrong with my head.” Now you’re thinking that this patient needs a bed because something isn’t adding up, but the charge nurse is telling you that there is only one bed left in the department and she wants to save it for a sick person.

 

Now what?:

  • It’s ultimately the physician’s responsibility to do the right thing for the patient, which is not always the easy thing.
  • Multiple red flags: Screaming, elderly woman, uncontrollable headache after passing out
  • Is the Narcan playing a negative role here in terms of being a huge source of bias?
    • Momentum bias (aka: Diagnosis momentum): “Once a diagnostic label has been assigned to a patient by another individual, it is very difficult to remove that label and interpret their symptoms with fresh eyes.”[1]
      • Would we view this case differently if the Narcan wasn’t given?
      • Does EMS giving Narcan clinch the diagnosis of an overdose or should the patient still be worked up?

You take a time out to run the board with your attending and see if you can discharge someone to free up a bed. No such luck. You then decide to rewind and go through the known patient history to get nursing on board that there are too many unanswered questions about this patient and she needs the last available bed. When the patient arrives she is grabbing her head and screaming. While you have seen patients come into the department acting, your gut is telling you something isn’t right with this patient. Turns out that the patient’s blood pressure is 240/190. At that point, you know this patient needs a head CT. Sure enough, CT shows a large intracranial hemorrhage.

Interested in how to treat an intracranial hemorrhage? Check out EM Board Bombs!

 

Take home points:

  • Learn to follow and trust your gut because it’s usually going to keep you safe
  • Always work as a team!
    • When you disagree with a coworker, figure out a way to do it without belittling them
    • If you are going to order something or make a decision that is different from how you would normally handle a situation, give the team a heads up, so everyone is on the same page.
  • Find a way to check your biases!
    • Avoid anchoring:
      • Anchoring: “Prematurely settling on a single diagnosis based on a few important features of the initial presentation and failing to adjust as new information becomes available.” [1]
      • Transitions of care are the easiest and most common places for anchoring biases to take hold
      • To avoid anchoring make sure you get the whole story, take in all the details and start from scratch using your own thoughts to come to a diagnosis
    • It’s not about whether you get the right end diagnosis, but rather that you do what is right for the patient along the way

 

 

References:

  1. https://first10em.com/cognitive-errors/
  2. https://medium.com/@kingsofar/why-you-should-always-trust-your-gut-feeling-when-in-doubt-87835752cb29
  3. https://www.inc.com/kat-boogaard/6-key-tips-to-respectfully-disagree-with-someone.html
  4. https://hbr.org/2016/03/how-to-disagree-with-someone-more-powerful-than-you

 

Listen to our Episode on their show ICH Over Easy

 

About Our Guests:

Dr. Blake Briggs is an Assistant Professor at the University of South Alabama in the Department of Emergency Medicine. Dr. Iltifat Husain is an Assistant Professor at Wake Forest University, Dept of Emergency Medicine. Together they co-founded the podcast EM Board Bombs!

 

Looking For More?

Interested in how to treat Intracranial Hemorrhage? Check out part 2 of this Clinical Grind on the EM Board Bombs podcast website!

Check us out at the ACOEP Spring Seminar: As the OFFICIAL podcast of the ACOEP, we will be hosting 3 LIVE shows at their upcoming Spring Seminar!! Visit www.acoep.org/spring for details to register for this amazing CME event!

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