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A lesson from the ED: Our hidden shortcoming

Two patients presented with similar symptoms — but they did not receive equal care.



I’m asked a lot what it’s like to be an ER doc. It’s as you might expect, the ER can be loud, noisy and hectic. You need to be willing to work at odd times, and to multitask. You need emotional intelligence and communication skills.

What is less obvious about practicing emergency medicine is how our cultural assumptions can influence our medical decisions, sometimes dramatically.

Two cases studies illustrate this point.

Shortly after I arrived at work one morning, a doctor tells me about a patient I’ll be caring for. He is described as combative and intoxicated. He’s 45 years old with a long history of polysubstance abuse. He’s coming in after being found down. His friends, who appear to be homeless, said he was drinking beer all evening.

The man is bit hypertensive, a little cold. He’s sleepy and he smells like alcohol. He’s refusing to follow instructions.

The staff assures me there are no signs of trauma. “Oh, you know him,” one said. “Here’s here all the time. By the way, he’s not even as drunk as he normally is.”

So the plan is to watch him, let him sober up. When he can walk in a straight line, he’ll be discharged back to the streets.

About an hour later, alarms go off. His heart rate’s going down, his blood pressure is going up. He starts seizing.

Were unable to resuscitate him.

Now contrast this with case No. 2. Another patient, also a 45-year-old man, comes in to be evaluated for altered mentation. His friends say he might have had a beer or two earlier, but he had a headache and went to get a nap somewhere.

He was found to be minimally responsive and unable to follow simple commands. He’s somnolent, but arousable, he appears to be confused.

The physician signing this out to me says, “I can’t make sense of this. There are no signs of trauma. There’s something wrong.”

She mobilizes all the resources necessary to get this person into the CT scan and get the labs going.

He’s under monitoring and, wow, has a brain bleed — a subarachnoid hemorrhage. Now his blood pressure is being aggressively controlled. We’ve elevated the head of the bed and put him on antiseizure medications.

We’re doing all the things we do to manage a subarachnoid hemorrhage until he’s ready to be transferred to Oregon Health & Science University as soon as the helicopter arrives.

There, doctors fixed his aneurysm and he was discharged essentially back to normal.

What happened here is two patients arrived in the same ER under care of well-trained, good ER doctors. One patient is put to the side of the room with the assumption that he’ll wake up and go home. For the other, we’ve mobilized all our resources and found something really significant that we could fix.

And therein lies the lesson. Physicians are intelligent people; we’ve got complex minds. We can be trained, we can learn, but we are still very subject to context.

What’s happening around us, our emotions, our own personal beliefs, judgments and preconceived ideas make up how we think. They can be helpful, but they also can result in cognitive bias.

So think about those two cases. One patient was drinking beer all night, was combative and unable to follow commands. He’s noncompliant. That draws a picture of someone that you just kind of want to put aside and let them recover.

Small, contextual clues affect your ability to just rationally and objectively look at what’s happening. And here’s the scary thing. All of us — all of us — suffer from cognitive bias.

So here’s my advice to anyone working in health care: Take a moment to be aware of your own cognitive bias. Try to get information from multiple sources, intentionally seek perspectives that differ from your own. Look for multiple explanations for an event. Be willing to change your mind when you’re confronted with evidence that contradicts the way you normally think.

Be open to changing your mind. It’s a blessing, and it might just save a life.

Tags: bias, culture, Eric Loeliger, lesson, medical decision
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If you have a question, please contact the author or relevant department directly.

8 Comments. Leave new

  • barbara hughes
    May 22, 2023 11:19 am

    This is a beautiful example of insight and humble, thank you.

  • Debbie Carole
    May 23, 2023 8:23 am

    I am a person who always finds it hard to express my thoughts, so I will simply say “Thank you”.

  • Genevieve Titus
    May 23, 2023 9:06 am

    The most valuable communication is honest communication. Thank you Dr. Loeliger for addressing this issue with transparency, humility and an open mind.

  • Kenneth Pricer
    May 25, 2023 2:55 pm

    Thank you for this article. We have had similar issues in our PCU at Rogue, as we see a lot of the same patients with similar presentations. It is always important that we as caregivers treat each patient individually and treat them based on their current presentation. Historical information is important however we need to meet the patient where they are at the moment.

  • Jennifer Johnson
    May 25, 2023 5:22 pm

    Thank you Dr. Loeliger for this excellent article and your previous presentation. I was deeply moved by your presentation and have shared this message with all my family and friends.

  • Tashia Cook
    May 26, 2023 9:34 am

    Wow, this article is so heartfelt, Thank you.

  • Excellent lesson for all of us to pay attention to. Thank you for the insightful article.

  • Peter Teichman, MD, MPA
    July 13, 2023 7:49 am

    Great advice I received decades ago from an Emergency Medicine doctor: “Judgement has nothing to do with it. You have to do the work every time.”


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