Welcome to season 4, episode 1 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

In this month’s case, a junior resident deals with some of the harsh realities of emergency medicine when she experiences the negative impacts of cognitive overload when caring for a sick patient.

[su_spoiler title=”MEdIC Series: The Concept” style=”fancy” icon=”caret”] Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the last Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we would love for you to get involved in the MEdIC series! Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.[/su_spoiler]

MEdIC: The Case of Cognitive Overload

By Dr. Sarah Luckett-Gatopoulos

Haley had come to think of the nurses in the emergency department as lifesavers. As a first year resident, she often found the nurses’ clinical acumen far exceeded her own; they sometimes reminded her to order investigations she hadn’t yet thought to initiate, and occasionally began the diagnostic workup with bloodwork while she was waiting to review with her staff preceptor. She started to think of the nursing staff as one of her safety nets in the department.

The department this evening was unusually busy and as a result of recent nursing shortages several nurses were working double shifts. When a nurse from the triage desk came into the department and asked Haley to see a tachypneic young man being wheeled into the resuscitation bay, naturally, she immediately put down the chart she was working on and went to assess the patient.

The 20-year-old man with a known history of asthma was tachypneic and appeared diaphoretic. The paramedics reported that he had been febrile and coughing for the past week, to the point that his ribs ached with each breath. He had tried using his rescue inhalers, but their effect was diminishing as the illness progressed. Over the past 24 hours his breathing had worsened and his cough was now productive of green sputum. Upon auscultating his lungs, Haley could hear extensive crackles in the right lung field with associated diffuse wheezing. Now highly concerned for pneumonia, she glanced up at the cardiorespiratory monitor which revealed that his heart rate was elevated at 135 and respiratory rate was 30. She figured that given the severity of his symptoms and presentation she should promptly initiate the departmental “sepsis protocol” while she waited to review the case with her attending, Dr. George.

‘Hi, I don’t think we’ve met. I’m Haley, one of the first year emergency medicine residents. I will be filling out the sepsis order set for this young asthmatic here in resuscitation bay 5. He looks pretty sick and I’m quite concerned about him. Could you start some of the work-up right away and I’ll review this with Dr. George as soon as he’s available.’ Haley signed the sepsis protocol, which included an order for extensive blood work, blood cultures and a litre of normal saline to be administered. She thought it would be most appropriate to review the case with Dr. George before proceeding with additional orders.

‘Not to worry,’ the nurse replied. ‘I’ve already started these,’ she gestured to the blood work order set in her hand. ‘I’ve put in 2 IVs, sent off blood work and cultures and he has some fluids running. I’ve also called the respiratory therapist to come assess him.”

Relieved that she had a veteran nurse on the case, Haley quickly reviewed the case with Dr. George. Following her discussion with her attending Haley signed a new order sheet, which included additional IV fluids, antibiotics, chest x-ray, urinalysis, and nebulizer treatments. She quickly dropped the new order sheet on the patient’s chart and then picked up a new patient’s chart. The next case was a simple finger fracture so she figured she’d have time to care for this patient while managing the sick asthmatic.

Upon completing the care for the patient with the finger injury, Haley was called into a trauma case and assisted with a chest tube. She then went back to review the board and realized she hadn’t checked on the asthmatic patient in almost 2 hours. She logged into the image viewing system to review his chest x-ray and was surprised to find it hadn’t been completed.

She approached the patient’s nurse and asked, ‘Do you know why our patient in resuscitation bay 5 hasn’t had his x-ray?’

‘Oh… I didn’t put that in. That’s your job.’ she replied. The nurse was simultaneously balancing the care for 5 emergency patients and appeared slightly flustered.

Haley glanced over at the patient who now appeared increasingly uncomfortable and fatigued. The respiratory therapist had started some nebulizer treatments but the patient appeared to be clinically deteriorating. Haley nervously asked the nurse, ‘How much fluid has he received? Did you give him anything for pain? Did you start the antibiotics?’

The nurse looked up at Haley, ‘I sent off blood work and started a bolus of saline as we discussed earlier. We can’t start additional interventions without a doctor’s orders. You need to order it if you want it done.’

Haley flipped through the order set in the patient’s chart and sure enough, her signed order sheet was right where she had placed it earlier. Haley had been so confident the orders would be completed. This nurse was one of the best she had worked with and she didn’t think she would have to get after her to do the work. Haley could feel her cheeks getting red… She kept thinking, ‘how could I have let this patient sit here for 2 hours without additional fluids or antibiotics! If he continues to deteriorate, this is on me!”

Discussion Questions

  1. How could Haley have avoided this dilemma?
  2. What strategies can physicians employ to lighten the cognitive load, decrease stress and avoid medical error?
  3. Should Haley disclose this medical error with the patient and how should she go about it?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This month’s experts

  • Dr. Amy Walsh
  • Dr. Jimmie Leppink

On October 14, 2016 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Tamara McColl, MD FRCPC

Tamara McColl, MD FRCPC

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba