Thread by @GIMaPreceptor

1/

A TALE OF TWO STENTS

a #twitternist #clinicalreasoning and #implicitbias reflection

Wanted to share 2vignettes with you #medtwitter, w permission (identities, some details changed)

Both involve rapid thinking, stretched foci of attention, unanticipated clinical events->

2/ first vignette :

Seeing last pt in morning session, 45 mins back

Finishing up, see another pt’s e mail & message on desk phone

Need 2finish up w pt in front of me, but odd message left in both places

Call back - 72 yo man, remote preDM but got that BMI to 23 long ago, ->

3/ mild lipids on lo dose statin, chronic bronciectasis, reflux. Know him 15 yrs as pt.

Pt: Dr. C, I feel better now, but ..(uh oh) when I woke had a discomfort in my L neck, felt sweaty. That’s all gone for a few hours now, I think I’m fine. But I don’t have my appetite ->

4/ pt has a medical background, had remained home, ‘symptoms passed’. Was struck by stomach/hunger being off. ‘Think I’m ok, I’ll keep you posted’

Me: uh, ____ , no no. There’s some chance this is your heart, you do realize? I know, not a lot of overwhelming RF, but .. ->

5/ let’s have some humility about the one thing that can hurt you. I’d like you to get to the ER now.

Phone medicine/triage. He hesitated, but relented.

Hemodynamically stable there, but ST waves - tall ones, inferior wall, big troponins. Cath/RCA stent 45 mins later.
->

6/ second vignette:

30 mins behind during an AM session. Knock on the door from my fabulous nurses triaging calls.

Dr. C, one of your pts, S, she’s called with some pretty bad abd upset/ache in pit of her stomach.

I come out of pt’s room - ‘excuse me for just a sec’->

7/ just a little angst crept in as I got pulled out .. still other pts waiting for me 😩, I’m behind

I recall S is a 63 yo woman, retired RN, trying to give up cigs for 10 yrs, very mild HTN (pronounced response to meds so far) and lipids, devoted to her Mom (also my pt), who->

8/ remained home for last 2 years after CVA from carotid dz.

Interesting thing - S was mid way thru 21 days of doxy for Lyme/ECM I dxd 2 wks prior, loves long walks w her dog, wooded areas in neighborhood.

Fast thinking, a blink of time -> doxy can be so hard on the stomach->

9/ Don’t want to fall more behind, this must be the doxy turning her stomach upside down ... Tell nurses, have her pick up some ranitidine, have some TUMS, have the next doxy after large meal.

I go back to pts. Phone medicine/triage.

S’s pain just crescendoed, unbearable->

10/ went to ER herself.

Hemodynamically stable, in pain. Risk factors, a woman told to pick up some ranitidine. T waves, tall ones. Troponins - big. Cath lab, stented 45 mins later.

What WAS my clinical reasoning during those intra session messages from other pts?

11/ I had it right in the man. Less RF, symptoms at time of call not that ‘typical’ (probably a word that should be stricken from chest pain evaluations).

I was way off in the woman. I anchored on so much ->

12/ Anchored on the Lyme, the doxy, the narrative that doxy bothers the stomach in many. Did not let the same humility in. She had risks for sure. Inferior walls give gastric symptoms all day long, I know that.

The availability #bias, the ‘within case’ momentum bias,
->

13/ the hint of overconfidence, the really fast confirmatory dialogue that only entertained a convenient interpretation. I’m a PGY24, I engaged in all of it. My heuristics helped the pt in one case, almost hurt the other; told by others ‘not a miss’.
But another larger worry ->

14/ the #implicitbias that screws MDs up, plain and simple, when it comes to CAD/MI in women. I think somewhere in my rushed metacognition it was there.

Name it
Think of it
Step back, diagnostic TIME OUT in women who can have coronary presentations - ‘what else can it be?’->

15/ ‘what part of the story doesn’t fit?’. Remember the forces that frame, name all the biases out loud as you’re working patients up, considering illness scripts and forming more complete differentials.

A nice piece re: diagnostic biases ->

PS->

rcpe.ac.uk/sites/default/…

16/ Both patients doing fine, thank you very much. And S has given up her cigs.

cc @DxRxEdu @rabihmgeha @andrewolsonmd @mmteacherdoc @reverendofdoubt