It was a privilige to meet Nicola Jakeman at the London EM trainee’s conference. She gave a great lecture on why it’s important for EM docs to understand Human Factors and was one of my co-judges for SimWars (she was the nice one….!).
Anyway, Nicola has asked us to help share some cases that reflect Human Factor issues in the ED. These run as cases in the ED, and you should work through them sequentially. At the end we would really like to hear what you think as if you think these are a good idea there are more to come. Please post comments on the case, the answers and……, well whatever you think.
As always the case is a teaching case (i.e. it’s hypothetical for learning purposes).
Good luck and may the Factors be with you……….
[DDET “Case 1. I can’t change my mind……..”] A woman presents to the ED with diarrhoea and vomiting. She also had vaginal bleeding, fainting and severe abdominal pain. The patient tells the doctor that she might have eaten some uncooked chicken the previous evening. She tells the doctor that she is about about 7 weeks pregnant. The patient is seen by a junior emergency physician and then reviewed by a junior gynaecologist. The gynaecologist diagnoses the patient as having gastroenteritis and discharges her.
The patient returns to the ED with increased pain in the early hours the following night following a collapse at home. She is found to be hypotensive and tachycardic. The notes written by the gynaecologist from the previous day are reviewed and the likely diagnosis of gastroenteritis is noted. The patient is seen by a junior emergency physician who is also managing a couple of other patients. There is one other ED doctor on shift and 30 patients in the department The patient is given a large amount of fluid for what is presumed to be dehydration secondary to gastroenteritis, and some morphine. The patient is not reviewed in the ED by a senior emergency physician or gynaecologist The patient is then discharged at 4 hours. At this point she remains tachycardic, although this has improved and her blood pressure is within the normal range.
Other than a B-HCG no other investigations are performed.
She returns a few hours later in extremis. Autopsy later reveals a large haemoperitoneum from a ruptured tubal pregnancy. [/DDET]
[DDET “Let’s stop and think……”] As part of our daily work as Emergency Physicians we are required to make multiple decisions which effect the treatment and care our patients receive. However, the process by which we make decisions is fallible and can lead to misjudgements and errors causing patient harm. Understanding the limitations of our personal decision making processes and being aware of those situations which predispose us to making an error can go some way to supporting safe decision making. Diarrhoea and vomiting is a recognised but unusual presentation of an ectopic pregnancy, and the inexperience of the junior doctors involved in this case probably played a significant role in the outcome. However, even the most senior clinicians make errors. Considering the case above describe factors which may have adversely influenced the decisions made by the Emergency Physician when the patient returned for the 2nd time?[/DDET]
[DDET ” Question 1: What might be the potential ‘red flags’ in this case that the medical and nursing staff should have been concerned about?”] [/DDET]
[DDET “Q1 – the model answer”]
The patient might have been seen at about 2am. The natural circadian rhythm is such that ideally we would be in our deepest sleep at this time. The doctor was probably fatigued. Fatigue predisposes us to:
- •Lack of concentration
- •Periods on inattention
- •Reduced vigilance
- •Reduction in level of alertness
- •Slow actions
- •Alteration in short term memory
- •Loss of critical analysis
These factors conspire to increase the risk of fixation error. This occurs when the practitioner concentrates solely upon a single aspect of a case to the detriment of other more relevant aspects. For example focusing on the diagnosis gastroenteritis, ignoring the fact that the patient has PV bleeding, a positive B-HCG and shock.
When we become fixated on one diagnosis, there is a risk that we look exclusively for evidence to support that diagnosis, ignoring evidence to the contrary, or manipulating it to meet the perceived diagnosis. This is termed confirmation bias.
The ED doctor may have perceived the gynaecologist to have more seniority than him/herself and be reluctant to challenge their diagnosis, despite evidence to the contrary. Cognitive overload may have been a contributing factor. The ED doctor was managing 3 patients simultaneously. She was probably interrupted frequently leading to breaks in his/her trains of thought. There is increasing evidence to suggest that the human brain can only manage 7 or perhaps just 5 things at once. Once pushed beyond this our capacity to make decisions is adversely effected.
Q 2. Thinking about the factors discussed in question one, describe strategies that you could employ under similar circumstances?”
[DDET “Question 2. – the model answer.”]
1. Recognise the critical impact of fatigue and sleep deprivation on decision making
2. Recognise when you are being unduly influenced by a pre-existing diagnosis.
3. Review all the evidence presented to you and acknowledge when something doesn’t fit your working diagnosis and consider alternative diagnoses. At this point you may have recognised that you have got overly attached to a particular diagnosis but can’t think of an alternative. It is important under these circumstances to seek a second opinion.
4. Recognise that interruptions and distractions can have a negative impact on decision making. When dealing with a complex or critical patient defer or deflect less important decisions. [/DDET]
[DDET “Let’s go through the key learning points here.”]
1. Decision making is fallible
2. Fatigue has a critical impact on decision making
3. Recognise those circumstances which would make you prone to becoming fixated on a particular diagnosis despite evidence to the contrary
4. Spend some time reflecting on patient’s you have seen, and consider the decision making processes that you have used to reach a diagnosis. [/DDET]
[DDET “References and further reading”]
1. M. Rall, P. Dieckmann. Crisis Resource Mangement to Improve Patient Safety. Euroanaesthesia. May 2005 107-112
2. Crosskerry, P. Achieving quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias. Academic Emergency Medicine November 2002, Vol. 9, No. 11 1184-1204
3. Confidential Enquiry into Maternal and Child Health (CEMACH) 2007 [/DDET]
Case studies on St.Emlyn’s
We do present hypothetical cases on St.Emlyn’s. These are based on the experience of our team as educationally active emergency physicians. For centuries doctors and nurses have used stories to teach and learn from each other. However, we are careful not to break any patient confidentiality rules. As a result if we present a case then it will always be fictional and not relating to any specific case or patient. For example if we present an (anonymised) X-ray or ECG we will create a clinical history that is compatible with the radiological/ECG findings but which does not relate to a specific time, location, patient or circumstance.
Whilst it may be argued that this detracts from the clinical learning we believe that patient confidentiality is more important in these matters.
We will create time, date, age, sex, details of the patient and their circumstances etc. Our cases are therefore an amalgam of different cases and experiences. Any resemblance to patients treated by us now, in the past or the future is entirely unintentional and accidental. Our cases are presented to help us all reflect and learn, in that way we might become better clinicians for our patient.
Vive la FOAM! (Free Online Medical Education).