Patient Care

Mind Games & Silence



Alone, I’m surrounded by strobes of memories—the baby monitor wresting us from sleep … muffled choking sounds … my wife holding our pale, stridorous 2-year-old … desperate attempts to clear his airway … the studied detachment of the 911 operator … paramedics … my wife running from the house without a jacket ... the fading ululations of the ambulance … silence.

I’m left in the bathroom, heart jack-hammering, holding a bloodied towel. Just 20 minutes earlier, I was cloaked in deep sleep. Now I’m shrouded with dread and cold sweat, my wife and son gone—leaving me to tend to our sleeping three-month-old daughter. The night ultimately ends well—perhaps comically, even—but not before being defined by three common cognitive errors.

Heuristics are those little shortcuts in logic that we utilize to solve common problems. They are bred from years of experience and helpfully get us home every night in time for dinner. Without them, medicine would be a painstaking, Everlasting Gobstopper-like journey through endless differential diagnoses.

History of Present Illness

It was a Monday night, and, after putting our kids down, my wife and I retired early to get a good night’s rest. An hour later, we awoke to gasping sounds from the monitor. My son, Grey, who was fine before bedtime, was panting and wheezing, unable to secure a full breath.

I immediately recalled that the night prior he had gagged on a dissolvable “gummy bear” vitamin. As he projected the appearance of someone who had aspirated something, we commenced manual sweeps of his mouth—feeling something in its deepest recesses. Gummy bear? Uvula? After numerous retching attempts to dislodge it, we moved on to Heimlich maneuvers. Nothing.

Just then, the paramedics showed up and took over, hearing this history of present illness.

Momentum Shift

An hour later, having secured a sitter for our sleeping infant, I showed up at the ED. Interestingly, the gummy-bear premise, nothing more than a harried utterance, had gathered the momentum of a boulder rolling downhill. The paramedics had relayed the possibility that our son might have aspirated a vitamin to the ED doctor, who relayed this certainty to the ear, nose, and throat doctor, who was actively scheduling operating-room time to bronchoscopically remove the offending foreign body.

It was all a bit like that childhood game of Telephone, in which the original message gets incrementally distorted with each telling, such that what starts as “Johnny told me he likes Lisa” turns into “Johnny crushed Lisa.”

My inner physician, elbowing the nervous parent aside, asked about the evidence for an aspiration. “The X-ray was negative, as was the exam, but the history suggests aspiration,” the ENT told me.

“What history?” I asked.

“That he has a history of ‘tonguing’ vitamins,” he said.

“Tonguing vitamins?” I responded, incredulously feeling the need to defend my child’s pill-swallowing honor. “Where did that story come from? We aren’t even sure we gave him a vitamin tonight.”

Nonetheless, the ENT was confident that “kids aspirate things all the time.”

Skeptical, I continued the debate. “But what if we hadn’t given that history? Would you still think of aspiration in this case?”

“Probably not, but then you did give us that history,” he replied. “So we need to bronch him.”

Culprit Revealed

Meanwhile, Grey was looking better with supplemental oxygen and a nebulizer’s worth of racemic epinephrine. His stridor took on more of a “barking seal” nature, and 30 minutes later, he developed a fever characteristic of croup. After a dose of steroids and another whiff of racemic epi, he was himself again, laughing the laugh of a wounded seal at the pulse oximeter, which backlit his big toe red. Comedy-club-level laughter replaced the look of death in the matter of an hour, as I was reminded of the resiliency of children. If only Mom and Dad could capture a bit of that.

Feeling a cocktail of relief and embarrassment—how could two physicians misdiagnose croup as an aspirated foreign body?—we readied ourselves for discharge. Just then, the ENT doctor came back in and told us the OR would be ready in a few hours. “But,” I inquired, “isn’t this just croup?”

“Most likely,” he replied, “but we can’t rule out aspiration without a bronchoscopy.”

It was then that I realized we (and our medical team) had fallen victim to some common heuristical errors. Heuristics are those little shortcuts in logic that we utilize to solve common problems. They are bred from years of experience and helpfully get us home every night in time for dinner. Without them, medicine would be a painstaking, Everlasting Gobstopper-like journey through endless differential diagnoses—in other words, your four-hour clerkship patient evaluations in medical school.

These shortcuts allow us to quickly recognize that a diaphoretic, 60-year-old man with diabetes, hyperlipidemia, and substernal chest pain has an acute coronary syndrome. We don’t spend hours thinking of Tietze’s syndrome, Boerhaave’s disease, and their ilk, because our mind quickly takes the shortcut to the right diagnosis. Although helpful, these shortcuts can cut both ways, occasionally resulting in thrombolytic therapy for an aortic dissection.

This is where Grey’s situation went wrong. My wife and I were victimized by the availability bias. This cognitive bias occurs when a recently encountered situation is given undue stature solely because of its proximity in time to the next event—i.e., it is “available.” So, because my son choked on a vitamin the night before, he must be choking on a vitamin the next night. (Even though we didn’t give him a vitamin and hours had passed since we put him to bed.) There is little connection between the two events, outside of the fact that aspiration is at the fore of your mind. This happens to us all the time. Think about the last presentation you attended about an obscure topic, only to amazingly find that the very next day, you had not one but two patients who surely required a workup for acute intermittent porphyria.

Common Practices

Anchoring bias is another common cognitive error in which we overly rely on one piece of information, the “anchor.” This was certainly in play during our ED visit. The mere mention of an aspirated foreign body was latched on to immediately. From there, tidbits of information that supported that diagnosis (something in the back of his throat on our exam, kids aspirate all the time) were kept, while the unsupporting evidence (negative X-ray and exam findings, fever, barking cough that awakes a kid at night) was jettisoned.

We fell prey to the momentum bias. This heuristical hiccup frequently wreaks cross-coverage havoc. You’ve seen this, I’m sure. Because the day team thought the renal failure was due to prerenal azotemia, the night team harmonizes, continuing to treat the patient’s bladder outlet obstruction with volume challenges. That is until someone—in my sphere, it’s usually the third-year medical student—asks if this could all be from the patient’s benign prostatic hyperplasia and medications.

After convincing our well-intentioned ENT colleague to call off the bronch, I was left with the important lesson that the ways in which our minds work, also well-intentioned, can cause us fits of trouble. I was left with the realization that the only way to mitigate the risk these cognitive shortcuts pose is to be constantly vigilant of their presence.

And, perhaps most importantly, I was left with an overstimulated 2-year-old high on the excitement of a hospital visit and large doses of adrenaline—a combination that left me desperately yearning for silence. TH

Dr. Glasheen is The Hospitalist’s physician editor.

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