Emergency medicine is a specialty that requires a level of comfort with uncertainty. No matter how good of a clinician you are, at the end of the day there will be patients that, despite solid medical care, will have an unexpected outcome. In addition to being potentially emotionally devastating, a serious miss can make us question our competence and shift our practice patterns from evidence- to anecdote-based. Dealing with these issues productively will be the topic of discussion in this months MEdIC.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and 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 fourth 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 be made available for download in pdf format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Unexpected Outcome

by Drs. Justin Hensley (@EBMGoneWild) & Teresa Chan (@TChanMD)

Melissa Armstrong walked into the Emergency Department, readying herself to take on her third evening shift in a row. It’d been a long week so far, and she felt a bit tired, but that’s because she’d seen more than 60 patients in the past 2 shifts. But this was the curse of being a newly minted attending at a busy urban hospital. You took the shifts that were given to you.

Walking by the Physician’s station, she noted Mike gesticulating wildly at her.

“Hey!  Melissa!” he said, as Melissa walked over to him. “Remember that lady with chest pain from yesterday that you sent home?”

Melissa felt that niggling sensation in the pit of her stomach. Those were NEVER good words.

“Well, she came back in a this morning, and she was pretty sick. We had to intubate her and send her to the unit. It looked like she had a giant pulmonary embolism.”

Melissa thought for a second and said, “Wait, the 34 year old?”

Mike nodded.

“But she didn’t have any risk factors!”

Melissa quickly rushed to the office, and pulled up the chart. She found her note and read it.  She had outlined her diagnostic reasoning. She had thought the patient was low risk according to the Well’s PE score, PE rule out criteria (PERC) was negative, so she hadn’t ordered a D-Dimer.

Diagnosis: viral syndrome.

What had she missed?

Her stomach turned and she was hit by a wave of nausea.

“Hey… you’re looking pale,” stated Mike, escorting Melissa to a chair. “Sit.”

He disappeared momentarily, and returned with a glass of ice water.


“But….She had a cough and a fever. Others in the family were sick. After meds, pt was feeling fine!” she sputtered. “Her vitals normal. Look, she’s Well’s low risk and PERC negative! What could I have done differently?”

“Well, all I know was what I saw this morning – tachycardic, hypotensive, D-Dimer of 6,400. Her CT-Pulmonary Angiogram showed a saddle embolism. If she didn’t have a PE yesterday, she definitely did this morning.”

“Dr. Armstrong… to Trauma bay 1. Dr. Armstrong…”

“Well, I guess it’s time to get to work, Melissa. They’re calling for you in Trauma. Come on, Melissa, shake it off!”

Melissa shook her head, trying to shake off the daze and walked over to the Trauma bay.

For the next 8 hours, went by quickly – but Melissa couldn’t shake that uneasy feeling in the pit of her stomach. Luckily, there were fewer patients than the day before. The major care patients weren’t an issue, but every viral illness in the quick care area, however, she found herself diligently documenting the Well’s, PERC and even ordered a few D-dimers in very low risk patients. Luckily, they all were negative.

At the end of her shift, she went upstairs to the intensive care unit to check on her patient from the day before.  The intensivist explained that the patient as doing better now that they had given her thrombolysis.

The next morning, Melissa awoke with that queasy feeling still in the pit of her stomach.  Her thoughts immediately jumped back to the case from two nights ago. What had she missed?

Picking up the phone, she called Kyle, her best friend from residency. Explaining the situation briefly over the phone, Kyle immediately insisted that he would be right over with coffee from her favorite neighborhood coffee shop.

Over a latte, Kyle had Melissa recount the story.

“I just don’t know what else to do. I feel like I can’t go back to work without people judging me, but to keep from missing things I feel like I have to over-investigate everyone so I don’t miss anything. Yesterday, I ordered 7 D-Dimers. I’m seeing PE everywhere. My confidence is just…. shot.”

Key Questions

Imagine you are in Kyle’s shoes.  How would you handle this?

  1. Melissa is obviously very upset about the case. How would you advise her to address her emotions?
  2. When applying evidence-based medicine, there are still times when there will be exceptions.  How do you handle those exceptions?
  3. Confidence plays a large role in our jobs as physicians.  How do you suggest Melissa proceed now that she is feeling very uncomfortable and second guessing herself?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published.

Click HERE for a link to the Expert & Community responses, which include words from:

  • Dr. David Marcus (@EMIMDoc) is the Chief Resident at the combined Emergency/Internal Medicine program at LIJ Medical Center in New York. He teaches Ethics, Professionalism, and Emergency Medicine at the Hofstra-North Shore LIJ School of Medicine. Dr. Marcus is a strong advocate of FOAM and other open educational resources. When not stalking the resuscitation rooms he can usually be found on Twitter or sailing Long Island Sound. Check out his blog, which includes a list of international EM, Critical Care and Medical Education conferences.
  • Dr. Ryan Radecki (@emlitofnote) is a board-certified Emergency Physician and Assistant Professor of Emergency Medicine at the University of Texas Medical School at Houston.  He blogs at Emergency Medicine Literature of Note, and is the principal of MDapplicants.com.  He practices Clinical Informatics, and develops tools to improve patient safety and support personalized medicine.  He is a member of the editorial staff of the Emergency Medicine Journal, and his work can be found in ACEP Now, and Emergency Physician’s Monthly.

Next week, you’ll be able to click here to go to the Expert Responses and Curated Community Commentary for the Case of the Unexpected Outcome (posted on May 2, 2014).

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.

Brent Thoma, MD MA
ALiEM Associate Editor
Emergency Medicine Research Director at the University of Saskatchewan
Editor/Author at CanadiEM.org
Brent Thoma, MD MA