3 Visits: a Clinical Grind

3 Visits: a Clinical Grind

Welcome back to another insightful episode of EM Over Easy! Your usual hosts, Andy, Drew, and John, dive deep into the fascinating and often challenging world of emergency medicine. This time, Andy bravely shares a personal case, a “clinical grind” focusing on three pivotal visits with a patient named Bob. Buckle up, because this story is a powerful reminder of the biases we all face, the importance of thoroughness, and the delicate art of delivering difficult news.

As Andy sets the stage, we learn that Bob was a familiar face in the emergency department during Andy’s residency – a “regular” who often presented with minor injuries or occasional COPD exacerbations. However, this narrative centers around three specific encounters that paint a much larger picture.

Visit 1: The Seemingly Simple Sore Throat

It was January of Andy’s intern year when Bob first presented with a chief complaint of a sore throat. In typical EAM Over Easy fashion, Andy throws it open to Drew and John for their initial thoughts on the differential diagnosis. The guys don’t disappoint, rattling off a comprehensive list from the common (strep, viral pharyngitis) to the more unusual (foreign body, even a hash pipe-induced oropharyngeal burn!).

This seemingly straightforward ESI level five “sore throat” complaint, however, is where Andy admits his first missteps occurred. Despite a positive rapid strep test and subsequent antibiotic prescription, Andy acknowledges a significant momentum bias. The late hour, the seemingly low acuity of the complaint, and the quick positive result led to a less than thorough evaluation.

“I did not get a good history on this guy,” Andy confesses. “I let him tell me the story. I took the positives he gave me, didn’t go after any of the negatives.” This lack of a comprehensive history meant missing crucial details. Drew and John astutely point out the importance of asking about changes in voice, difficulty swallowing, and other red flags. Andy further elaborates on the missed opportunities: a deeper dive into his significant smoking history (90 pack years!), family history of lung cancer, and exploring the nuances of his fever, weight changes, and associated symptoms.

The physical exam was also limited, focusing primarily on the throat. While Drew offers a relatable perspective, acknowledging that a full head-to-toe exam isn’t always feasible for every low-acuity complaint, Andy recognizes the value of a more complete assessment, even in seemingly minor cases. Basic elements like checking pulses or a more thorough chest exam were overlooked.

John aptly labels this situation as a classic example of confirmation bias – focusing on the information that supports the initial (and seemingly correct) diagnosis of strep throat while overlooking potential contradictory or additional findings. However, both Drew and John offer a degree of absolution, suggesting that at the time, with the information presented, the management was likely within the realm of reasonable practice. They emphasize the importance of clear discharge instructions and follow-up advice, which Andy confirms were provided.

Visit 2: The Concerning Neck Mass

Fast forward three months. Bob returns, this time with a significantly more alarming chief complaint: a neck mass. He attributes its onset to around the time of his previous sore throat visit. What started as a small “spot” had, over three months, grown into a “softball size mass.” Accompanying this were significant red flags: a 40+ pound unintentional weight loss, night sweats, myalgias, unilateral arm swelling and discoloration, and difficulty swallowing leading to severely reduced oral intake.

The tone shifts dramatically. John immediately labels this “Cancer Day,” and the gravity of the situation is palpable. He expertly walks through the differential, highlighting how the constellation of worsening symptoms, the inappropriate timeline for a simple infection, and the multi-system involvement strongly point towards a more sinister etiology. Unintentional weight loss, in particular, is flagged as a crucial “deeper thing” to investigate.

Despite the obvious concern, John offers a crucial perspective: the initial diagnosis of strep throat was likely correct. The subsequent development of a malignancy and its associated symptoms doesn’t necessarily mean the initial management was flawed. Drew echoes this sentiment, emphasizing that reactive lymphadenopathy is a common finding in infections like strep throat, and the progression to a significant mass over three months doesn’t automatically indicate a missed diagnosis during the first visit. He even suggests that the initial visit might have made Bob more aware of his body, leading to earlier detection of the growing mass.

Andy revisits his initial assessment, acknowledging the missed opportunities in the history – the significant smoking history and family history of lung cancer. While these wouldn’t have necessarily changed the strep diagnosis, they might have prompted a broader differential and perhaps a more comprehensive initial exam.

The physical exam during this second visit reveals the extent of Bob’s condition: the large neck mass, significant unilateral arm swelling and discoloration (likely due to venous obstruction), chest wall bulging, and a diminished pulse in the affected arm. Imaging, including a CT of the chest, abdomen, and pelvis, reveals a staggering finding: a 12-centimeter right lung tumor with extensive metastasis to the neck, liver, kidneys, bladder, and lymph nodes.

The Delicate Art of Delivering Devastating News

The conversation then turns to one of the most challenging aspects of emergency medicine: breaking the news of a serious diagnosis like cancer. Andy, reflecting on his training, notes the varying approaches he’s witnessed, with some leaning towards leaving this difficult conversation for the inpatient team. However, both Drew and John vehemently disagree with this approach.

John emphasizes the importance of understanding the patient’s perspective first. Has Bob already considered cancer as a possibility? This will shape the conversation. Regardless, John advocates for a direct yet empathetic approach. After delivering the news, he stresses the critical need to pause, allowing the information to sink in. His next step is always to ask if the patient wants anyone present – family, friends, or even the chaplain.

Drew underscores the importance of remembering that this is the patient’s information, and withholding it until inpatient admission does a disservice. He highlights the value of involving the entire care team – nurses and techs often have a strong rapport with patients and can provide valuable insights and support. He also emphasizes the need to inform the nurse before delivering bad news to avoid awkward or insensitive interactions.

John shares a powerful technique he’s learned: after delivering the news of cancer, he creates a brief space for the patient to process by stepping away for a few minutes before returning to answer questions. He explains that immediately overwhelming the patient with details often leads to them not absorbing anything beyond the initial shock.

Both Drew and John stress the importance of sitting down with the patient, making eye contact, and demonstrating empathy during this difficult conversation. John even describes showing patients their imaging to help them understand the findings visually. He emphasizes acknowledging the complexity of the situation and promising ongoing support and answers.

Conclusion: Learning from Every Visit

Bob’s case, as Andy poignantly shares, is a powerful reminder of the complexities inherent in emergency medicine. It highlights the ever-present risk of cognitive biases, the critical importance of a thorough history and physical exam, even in seemingly low-acuity presentations, and the profound impact of how we deliver difficult news.

While the initial sore throat visit didn’t reveal the underlying malignancy, the case serves as a valuable learning opportunity. It underscores the need to challenge our assumptions, to dig deeper into patient histories, and to maintain a broader perspective, even when faced with common complaints.

The second visit underscores the rapid and devastating progression some diseases can take and the importance of recognizing and acting upon red flag symptoms. Finally, the discussion about breaking bad news offers invaluable insights into the human side of emergency medicine – the empathy, communication skills, and support needed when delivering life-altering diagnoses.

Thank you, Andy, for your vulnerability in sharing this challenging case. It’s through such honest reflections that we can all learn and strive to provide the best possible care for our patients, every single visit.