Itâ€™s important to be wrong now and then. Not just for the usual blather about being humble, understanding cognitive biases, or even nailing the Kobayashi-Maru test.
No, it’s important to be wrong in the right sort of way, a willingness to be humble in the interest of patient care. Let me explain!
Case #1: I was sooo right.
EMS brought in a middle-aged male who was â€œfound on the floor,â€ having been their for an unknown period of time. Their medical history and medications were also unknown, and his altered mental status didnâ€™t help. Vital signs were okay, although the heart rate was unexpectedly low for someone who looked sick and dehydrated. While my resident was examining the patient, I talked with Sara, the paramedic, about the ECG.
â€œHuh,â€ I said to Sara, â€œfunny itâ€™s so slow, since he looks dry as dust. T-waves also look a bit funky â€“ I wonder about hyperkalemia. Hey, don’t be afraid to empirically treat if the history and ECG make you suspicious.â€
We grabbed our own ECG in the ED:
This was also supportive of hyperkalemia, and so I pushed calcium before waiting for the lab results. The potassium turned out to be 6.3.Â #JediECGskillz Â #AmIGoodOrWhat
Case #2: Â #OrWhat
An elderly female with no prior ECGs, or records of any sort, was brought in by EMS with a report of â€œaltered mental status.â€ She actually seemed mostly okay to me, but the veteran paramedic, Chris Lovell from Norwalk, showed me the ECG:
“Now, I know what you’re thinking…” Yeah, it was paced, so some of you might say â€œyou canâ€™t tell anything from the ECG.â€ Probably should have listened to you! Two points in my defense however:
TL;DR? You might see loss of pacer capture, or significant QRS widening compared with an old ECG. Some of the better examples:
Second, did I mention I have Jedi-like skills in detecting hyperkalemia?
I proceeded to personally push 3 grams of calcium gluconate, and rechecked the ECG to document my â€œwin.â€
No changes whatsoever. The potassium was completely normal.
Okay, so I was wrong. But was it a capital-F â€œFail?â€ (Of course, my short answer is â€œNo.â€)
Hereâ€™s the longer answer why this was NOT a fail.
If an ER doctor tells you, with pride, that their accuracy in diagnosing STEMI is 100%, since they have never sent a â€œfalse-STEMIâ€ to the cath lab, then they are either (best-case scenario) lying, or they are (worst-case scenario) very bad at their job.
If you never send a â€œfalse-STEMIâ€ to the cath lab, it means that you are probably NOT picking up on a bunch of â€œtrue-STEMIs.â€ If you arenâ€™t taking a chance on the small or subtle STEMIs, then you might be hurting patients.
The surgeons have understood this about appendicitis for generations. At least before CT scans started being used, a good surgeon was defined by the number of â€œnegativeâ€ appendectomies you performed:
- Too many meant you were too quick to cut, and had no sense of clinical judgment.
- Too few meant you were missing â€œtrue cases,â€ letting them perforate & get septic.
We could view empiric treatment of hyperkalemia like that â€“ if you arenâ€™t overtreating at least sometimes, then you are probably missing critical chances to treat a potentially lethal condition. And unlike going to the OR or the cath lab, the EMS therapy (calcium chloride) is pretty benign.
So perhaps we should take pride in over-reacting (within your guidelines and protocols, of course). Maybe we could start to track our â€œnegative-Kâ€ rates, and even start to brag about them!