Friday, January 8, 2016
Diagnostic errors and the 'fog of war'
Most readers have familiarity with the phrase “fog of war.” In hospital medicine we often exist in a complex, chaotic situation. We have many patients, in various stages of their admission, beepers beeping, consultants consulting, sign outs and discontinuity. I have experienced this problem too often. Last week was a classic example.
The patient had a past history of IV drug abuse, but now had staph septicemia. He was in the middle of a 6-week hospitalization for IV antibiotics. He had several complications that were improving.
I joined his care on a Monday. That day he had no major complaints. The housestaff team asked for help in treating his new hypertension.
The next day he complained of shoulder pain. On examination he had full range of motion (both active and passive) but some tenderness with palpation.
On the third day the medical student reported that he had developed hyper-defecation and abdominal pain. The blood pressure remained poorly controlled.
The entire team expressed their puzzlement in trying to understand his complaints.
Then I recalled from day 1 that his IV morphine had been discontinued on Sunday.
His symptoms of opiate withdrawal had blossomed as we saw him each day. I asked him if he had ever had opiate withdrawal before, and he told us that his symptoms then were identical to his present symptoms.
A modest dose of opiates for 2 days and starting methadone have cured his hypertension and all his other symptoms.
As I write the story, I suspect many had suspicions before reading the answer. The presentation reads much easier than it felt. We had various clues but they did not come in a simple bundle.
As we rounded on 15 patients, he seemed more stable than many. We probably did not devote enough time to trying to analyze his symptoms.
Diagnostic errors and delays seem so simple in retrospect, but all seasoned clinicians know better. When you do not know that you are searching for a new diagnosis, you would love for someone to tell you that 1 exists. Too often in the fog of war, we fail to attend to some clues that we need to reopen our thought processes.
A computer program could have taken the symptoms and discovered the correct diagnosis, if (and only if) we knew to enter the symptoms.
I was confused, until I had a sudden epiphany. I knew the symptoms of opiate withdrawal, but I had to make the important leap of tying various symptoms into 1 knot that need unraveling.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
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db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
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Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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One of the most popular anonymous blogs written by an emergency room physician.