Little Things Mean A lot

One night when I had just started working in the big city ED, we had a ambulance come in the wee hours of the morning and the last hours of a long 12 hour shift.

 The call was for "leg pain" in a 48 year old female. When she rolled through the door, something didn't seem quite right. She appeared to be in excruciating pain, but EMS said her heart rate was brady at 54. Increasing pain should increase the heart rate. She also just didn't look well. I called for a 12 lead EKG before she was even off the gurney and started an IV and labs. 

A few minutes later, the ED doc held the EKG in his hand. "Who ordered an EKG for leg pain?" I explained my decision. Turns out she was in new onset of third degree heart block. 

We've had cases where nurses have caught heart attacks based on nothing more than a hunch. I've seen cases where present like a stroke and a blood sugar reveals that they were really just hypoglycemic. 

Little things, can protect you from missing the right diagnosis, the right course of action. 

Just had another case like this the other night. Call was for a 37 yoa male near syncope while playing pool in a bar. Hx of vertigo in the past but pt states "this is different." The Medic got the 12 lead = AFIB with RVR 170 - 190 with no prior history. If you think, "should I get a 12 lead/check a blood sugar" the answer is almost always yes.

Here's a good article on how doing little cheap things can reduce the risk of big failures. It's based on the new book Antifragile, which I haven't read yet - but based on this article, I think I'll check it out. 

"Thus the decision to withhold the 12-lead is in Taleb’s view, a fragile one. If you lose, you (and the patient) can be broken. You want always to avoid the state of fragility. You want to be antifragile. Your gut may tell you it’s not cardiac, but in this situation where the possibility of failure exists, having a redundant system like a 12-lead provides you protection. At a low cost of doing a 12-lead, you prevent a catastrophe – missing a STEMI.

Minor exertion versus a patient’s death. The potential gain and the potential loss from the bet that it is not cardiac are not equal. Low upside if you are right, big downside if you are wrong."

Antifragile: Things That Gain from Disorder
Risk Assesment: From Streetwatch blog