Why We Don't Make the Diagnosis

[Arcan57]

The "Do EM Docs Diagnose" thread got me thinking about the meta-game of EM and the various reasons why we finish our care for the patient without knowing what's wrong with them. Some of it is going to be heuristic errors (anchoring bias, etc.) but a lot of the time we whiff on the diagnosis without any cognitive errors on our part. This topic is important because if we don't know the why behind not making a diagnosis we're less able to defend ourselves from malignant admitting docs. We are also more likely to allow unacceptable errors to creep through because we've falsely assigned a patient to a "don't know, don't care" category when it comes to diagnosis.

In no particular order, the most common reasons I don't get the correct diagnosis are:

1) Time - missing the diagnosis because the disease hadn't declared itself yet. The time we have to make a diagnosis is one of the most highly variable parts of EM yet informs so much of how we practice. The majority of us trained in highly inefficient hospitals were LOS was 4-6 hrs for dc'ed patients which is not the system most of us work in. If I have an hour to make a diagnosis on a patient I'm going to be significantly less accurate than if I have 3-4 hrs.

2) Multiple diagnoses - the COPD/CHF/hx of PE with dyspnea pt falls into this category. The admitting doc usually wants a single reason they're coming into the hospital, but often it's a patient with multiple chronic diseases presenting with a common sequelae of multiple of their diseases. In reality they're going to get treated for everything (+/- tested for everything) and at some point they'll drift back to their unstable baseline and be dc'ed. Pretty much everyone (EP and hospitalist) is ok with this one.

3) Misleading lab work - the dirty urine on the 78 yo appy, the falsely low BNP on the morbidly obese CHF pt, the CXR that is read as edema in the CHF pt that actually has multi-focal pneumonia. These are the cases where we get crucified by the upstairs docs, who have the luxury of #1, for missing the diagnosis. It's also a common point of contention because everyone has different ideas about how far to carry-on the work-up in the setting of a reasonable explanation for pt's symptoms.

4) Inadequate history - pt unable to give a good hx, my failing to f/u on an important point, etc. NH pts would be the prototypical example, since the reason they were sent to the ED is essentially unobtainable unless they had an acute event with family watching. Also, how many AMS patients do we admit that are there because of polypharmacy but no one even has a medlist, let alone when a particular med was actually started or changed in dose?

5) Not an acute condition - a category where we are fine not making the diagnosis but without heavy scripting the patient leaves pissed. Your epigastric abdominal pain for 6 months that you came to the ED for tonight "just because" or the chronic back pain patients w/o new neuro deficits being a prime example. Of note, there are a ton of these that get misclassified as acute because of #4.

6) Diagnostic test unavailable in ED - suspected GERD, suspected unstable angina, most tox stuff that comes in without a good hx, subacute/chronic MSK pain that needs an MRI, etc. Honorable mention to the STEMI mimics and Takotsubo syndrome

7) Frequent flyer with poorly documented hx - you all know this patient. It's the one the staff says comes every other week complaining of some chronic condition but when you look it's actually been months since they have been there and you can't tell that they've had an appropriate work-up for their symptoms within the last couple of years.

8) Ignorance/don't care - ARF that's not from dehydration or sepsis, any of the in-born errors of metabolism, differentiating congenital heart diseases,etc.

9) Psych/medication related - self-explanatory

Anyone else care to share their more common reasons for not making the diagnosis?

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[dotcb]

It's primarily a time issue.

Most of the time we can tell if a patient needs to be admitted based on no testing.

At our ED you're gonna get 1 round of testing and possibly some imaging. We're going to treat your symptoms according to how sick we think your are. We might add on a few studies to the blood samples in the lab as we're calling the admission. If you need to be admitted, that's all we're gonna do. The inpatient team can take it from there.

Our department has the experience of opening an observation unit in the last year. We've discovered that with time, many things declare themselves - fever spikes, patient needs O2, pain goes away.

But many things do not declare themselves, and additional time and additional testing doesn't add much - ex. chronic abdominal pain, gastroparesis, etc. We could do 7 rounds of testing and it wouldn't change the outcome.

Some accuse ED physicians of not caring about patients or their diagnoses. That's actually not true at all. I would love to be able to diagnose everyone, including people who are going home w/ vague symptoms. But my first priority is the people coming to our ED w/ emergency conditions. If you don't have one, you're stable enough to get an outpatient work-up. We're not going to test your vitamin or thyroid levels while the ED's closed to ambulance traffic. Other fields, and often patients don't understand this viewpoint, but it is the right thing to be doing and it's how we fit in the healthcare system.

 

[deleted109597]

7) Frequent flyer with poorly documented hx - you all know this patient. It's the one the staff says comes every other week complaining of some chronic condition but when you look it's actually been months since they have been there and you can't tell that they've had an appropriate work-up for their symptoms within the last couple of years.

This part is the worst. It is simply unacceptable in the era of EMR that a patient can be seen and not have their information collected. However, I personally have seen a patient two days in a row, but on the second visit, none of the prior stuff is there. Then you look them up by birthday and find 2 or 3 other records for the same patient (personal record is a guy who had 13).

 

[gro2001]

This part is the worst. It is simply unacceptable in the era of EMR that a patient can be seen and not have their information collected. However, I personally have seen a patient two days in a row, but on the second visit, none of the prior stuff is there. Then you look them up by birthday and find 2 or 3 other records for the same patient (personal record is a guy who had 13).

And the reverse also happens, especially with undocumented folks. You will look back and notice their blood type change from visit to visit. Usually happens when several people are using the one documented guy's identity.

 

[Arcan57]

This part is the worst. It is simply unacceptable in the era of EMR that a patient can be seen and not have their information collected. However, I personally have seen a patient two days in a row, but on the second visit, none of the prior stuff is there. Then you look them up by birthday and find 2 or 3 other records for the same patient (personal record is a guy who had 13).

We have issues with that. We had a guy that was a GSW victim that had just been dc'ed from our Level 1 who had acute urinary retention (and GSW had been in groin). It took a call to the trauma surgeon at the level 1 to confirm that he actually had been treated there. They never merged his AKA account, so with the exception of his family swearing up and down he came across as lying.

 

[la gringa]

We have issues with that. We had a guy that was a GSW victim that had just been dc'ed from our Level 1 who had acute urinary retention (and GSW had been in groin). It took a call to the trauma surgeon at the level 1 to confirm that he actually had been treated there. They never merged his AKA account, so with the exception of his family swearing up and down he came across as lying.

i had one recently too... the nurse and i were playing freakin' law and order on the guy b/c he could barely get his story straight. even had to call local PD to make sure there was an MVC c/w his story in the area b/c his injuries weren't c/w an MVC. ohhhh humanity...

 

[Birdstrike]

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[Arcan57]

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Excellent contribution.