Our Brains Against Us: Cognitive Errors and Debiasing w/ Dr. Quinn Cummings
Sep 03, 2021
Show notes
In this episode I talked with Dr. Quinn Cummings (@resus_bae) about the topic of
cognitive bias and some ways we can reduce the influence of biases in our
practice. Quinn is an emergency physician with a special interest in this
topic.
During an average shift an emergency medical provider makes
hundreds to thousands of decisions. To make these decisions, our brains use a
combination of conscious and subconscious information. We tend to think that all
our decisions are made objectively but, in fact, much of our decision making
comes from knowledge or ideas that we are not even aware of. This is the
concept of cognitive bias. A cognitive bias is a systematic error in thinking
which can skew our ability to process information properly and accurately. This
can lead to an improper diagnosis or treatment path for our patient. There are
numerous examples of specific biases such as anchoring bias, confirmation bias,
premature closure, etc. We discuss a few examples in the podcast but we
encourage you to research more to see which ones you may be more susceptible to
(see resources below).
As always please feel free to share feedback, comments, or
questions!
Croskerry, P. The Importance of Cognitive Errors in Diagnosis and Strategies to
Minimize Them. Academic Med. August 2003, 1-6.
Croskerry, P et al. Patient Safety in Emergency Medicine.
Lippincott Williams & Wilkins, 2009.
Thomas, D. D., & Mustafa, Y. Design for cognitive bias.
Jeffrey Zeldman / A Book Apart. 2020.
Croskerry P. Cognitive forcing strategies in clinical
decision making. Ann Emerg Med 2003;41(1):110–120.
Croskerry P. The feedback sanction. Acad Emerg Med. 2000
Nov;7(11):1232-8. doi: 10.1111/j.1553-2712.2000.tb00468.x. PMID: 11073471.
Caplan R.A., Posner K.L., Cheney F.W.: Effect of outcome on
physician judgments of appropriateness of care. JAMA 1991; 265: pp. 1957-1960.
Abraham Kaplan (1964). The Conduct of Inquiry: Methodology
for Behavioral Science. San Francisco: Chandler Publishing Co. p. 28. ISBN
9781412836296.
Allison, Scott T; Messick, David M (1985). “The group
attribution error”. Journal of Experimental Social Psychology.
21 (6): 563–579. doi:10.1016/0022-1031(85)90025-3
Lambe KA, O’Reilly G, Kelly BD, et al. Dual-process
cognitive interventions to enhance diagnostic reasoning: a systematic review.
BMJ Quality & Safety 2016;25:808-820.
Benau EM, Orloff NC, Janke EA, Serpell L, Timko CA. A
systematic review of the effects of experimental fasting on cognition.
Appetite. 2014 Jun;77:52-61. doi: 10.1016/j.appet.2014.02.014. Epub 2014 Feb
27. PMID: 24583414.
Lowe CJ, Safati A, Hall PA. The neurocognitive consequences
of sleep restriction: A meta-analytic review. Neurosci Biobehav Rev. 2017
Sep;80:586-604. doi: 10.1016/j.neubiorev.2017.07.010. Epub 2017 Jul 28. PMID:
28757454.
O’Sullivan ED, Schofield SJ. Cognitive bias in clinical
medicine. J R Coll Physicians Edinb. 2018;48(3):225-232. doi:10.4997/JRCPE.2018.306
Agitation w/ Reuben Strayer
Aug 26, 2020
Show notes
On this episode I am lucky to have Dr. Reuben Strayer on to discuss the management of agitated patients. Dr. Strayer is an emergency physician in New York City and has interest and expertise in the management of agitation as well as sedation and airway management. Agitated patients are often challenging to treat. They require a high-level of assessment skill and a tailored treatment plan. There is a spectrum of agitation and it is important to determine where your patient falls to choose the correct management. This episode is a framework of the agitation spectrum and treatment options for the various types of patients we see.
Ketamine dose continuum (all doses IV unless indicated) With ketamine the two therapeutic ranges are analgesic and dissociation. We generally avoid the two middle ranges. For agitation, the only reliable use is to target dissociation using at least 3 mg/kg IM.
Vilke GM, Payne-James J, Karch SB. Excited delirium syndrome
(ExDS): Redefining an old diagnosis. J Forensic Leg Med.
2012;19(1):7-11. doi:10.1016/j.jflm.2011.10.006
Riddell J, Tran A, Bengiamin R, Hendey GW, Armenian P. Ketamine as a first-line
treatment for severely agitated emergency department patients. Am J Emerg
Med. 2017;35(7):1000-1004. doi:10.1016/j.ajem.2017.02.026
Parsch CS, Boonstra A, Teubner D, Emmerton W, McKenny B, Ellis DY. Ketamine
reduces the need for intubation in patients with acute severe mental illness
and agitation requiring transport to definitive care: An observational study. EMA
– Emerg Med Australas. 2017;29(3):291-296. doi:10.1111/1742-6723.12763
Miner JR. Ketamine is a good first-line option for severely
agitated patients in the prehospital environment. Am J Emerg Med.
2018;36(3):501-502. doi:10.1016/j.ajem.2017.12.015
Michaud A. Restraint related deaths and excited delirium syndrome
in Ontario (2004-2011). J Forensic Leg Med. 2016;41:30-35.
doi:10.1016/j.jflm.2016.04.010
Linder LM, Ross CA, Weant KA. Ketamine for the Acute Management of
Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy.
2018;38(1):139-151. doi:10.1002/phar.2060
Isbister GK, Calver LA, Downes MA, Page CB. Ketamine as Rescue
Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the
Emergency Department. Ann Emerg Med. 2016;67(5):581-587.e1.
doi:10.1016/j.annemergmed.2015.11.028
Hopper AB, Vilke GM, Castillo EM, Campillo A, Davie T, Wilson MP.
Ketamine use for acute agitation in the emergency department. J Emerg Med.
2015;48(6):712-719. doi:10.1016/j.jemermed.2015.02.019
Gonin P, Beysard N, Yersin B, Carron PN. Excited Delirium: A
Systematic Review. Acad Emerg Med. 2018;25(5):552-565.
doi:10.1111/acem.13330
Khokhar MA, Rathbone J. Droperidol
for psychosis-induced aggression or agitation. Cochrane Database Syst
Rev. 2016;12(12):CD002830. Published 2016 Dec 15.
doi:10.1002/14651858.CD002830.pub3
Lai PC, Huang YT. Evidence-based
review and appraisal of the use of droperidol in the emergency
department. Ci Ji Yi Xue Za Zhi. 2018;30(1):1-4.
doi:10.4103/tcmj.tcmj_195_17
Klein LR, Driver BE, Miner JR, et
al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for
Treating Acute Agitation in the Emergency Department. Ann Emerg Med.
2018;72(4):374-385. doi:10.1016/j.annemergmed.2018.04.027
Nobay
F, Simon BC, Levitt MA, Dresden GM. A prospective, double-blind, randomized
trial of midazolam versus haloperidol versus lorazepam in the chemical
restraint of violent and severely agitated patients. Acad Emerg Med.
2004;11(7):744-749. doi:10.1197/j.aem.2003.06.015
Silbergleit R, Lowenstein D,
Durkalski V, Conwit R; Neurological Emergency Treatment Trials (NETT)
Investigators. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival
Trial): a double-blind randomized clinical trial of the efficacy of intramuscular
midazolam versus intravenous lorazepam in the prehospital treatment of status
epilepticus by paramedics. Epilepsia. 2011;52 Suppl 8(Suppl
8):45-47. doi:10.1111/j.1528-1167.2011.03235.x
Ramsay RE, Wilder BJ, Uthman BM, et al. Intramuscular fosphenytoin
(Cerebyx®) in patients requiring a loading dose of phenytoin. Epilepsy Res.
1997;28(3):181-187. doi:10.1016/S0920-1211(97)00054-5
Hopkins U, Arias C. Large-volume IM injections: a review of best
practices. Oncol Nurse Advis. 2013;4(february):32-37.
Harrington L. Administer single-site 30-mL intramuscular
injection? Medsurg Nurs. 2005;14(6):379-382.
Del Mar CB, Glasziou PP, Spinks AB, Sanders SL. Is isopropyl
alcohol swabbing before injection really necessary? Med J Aust.
2001;174(6):306. doi:10.5694/j.1326-5377.2001.tb143279.x
Fleming DR, Jacober SJ, Vandenberg MA, Fitzgerald JT, Grunberger
G. The safety of injecting insulin through clothing. Diabetes Care.
1997;20(3):244-247. doi:10.2337/diacare.20.3.244
Khawaja RA, Sikanda R, Qureshi R, Jareno RJM. Routine skin preparation with 70% isopropyl alcohol swab: Is it necessary before an injection? Quasi study. J Liaquat Univ Med Heal Sci. 2013;12(2):109-114.
Altered Airways – A dive into asthma and COPD – Part II
Jan 13, 2020
Show notes
This is Part II of my discussion with Michael Perlmutter on asthma and COPD management. In this episode we discuss interventions used for advanced/severe asthma exacerbations including magnesium, epinephrine, ketamine, non-invasive positive pressure ventilation, and advanced airway management.
Altered Airways – A dive into asthma and COPD – Part I
Dec 24, 2019
Show notes
In this two-part series I discuss asthma and COPD. These diseases are complex and have a spectrum of severity and presentation. The sickest of these patients require prompt, aggressive care to prevent further deterioration so a thorough understanding of the disease is essential. Michael Perlmutter, flight/critical care paramedic and medical student, joins me for a great conversation on prehospital management of these diseases. This is Part I which covers pathophysiology, diagnosis, and early management. Part II will be released in a couple weeks and will cover treatments used in our more critical patients and advanced stages of exacerbations. As always, please follow us on our various social media accounts and let me know if you have any questions, feedback, or personal experiences to share.
Note: in the podcast at one point I say ipratropium and tiotropium are muscarinics but they are muscarinic antagonists.
Below are some quick guides to home management of asthma and COPD. The treatment approaches between the two diseases vary. One of the biggest differences is that asthma patients are started on inhaled steroids relatively early in their progression but if you see a patient with COPD on an inhaled steroid, they are likely late in their disease process. By looking at a patient’s home medications you can infer some information about the severity and pathophysiology of their underlying disease.
Alabed S, Sabouni A, Providencia R, Atallah E, Qintar M, Chico TJ. Adenosine
versus intravenous calcium channel antagonists for supraventricular tachycardia.
Cochrane Database Syst Rev. 2017 Oct 12;10:CD005154. doi:
10.1002/14651858.CD005154.pub4.
Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, Lobban T, Dayer M,
Vickery J, Benger J; REVERT trial collaborators. Postural modification to the
standard Valsalva manoeuvre for emergency treatment of supraventricular
tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 Oct
31;386(10005):1747-53. doi: 10.1016/S0140-6736(15)61485-4.
Bibas L, Levi M, Essebag V. Diagnosis and management of supraventricular tachycardias. CMAJ. 2016;188(17-18):E466–E473. doi:10.1503/cmaj.160079
Hafeez Y, Armstrong TJ. Atrioventricular Nodal Reentry Tachycardia (AVNRT) [Updated 2019 May 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499936/
How We Make Easy Airways Hard – Part 2
Aug 29, 2019
Show notes
This is part 2 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving endotracheal intubation and avoiding common errors that make airway interventions less likely to be successful.
Airway Checklist Examples
Anything worse than grade 2a is ideally managed using a bougie. Image: nurse-anesthesia.comGrade 3a should be optimized if possible but can usually be managed using a bougie. Grade 3b cannot be intubated and must be optimized.
How We Make Easy Airways Hard – Part 1
Aug 12, 2019
Show notes
This is part 1 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving basic airway skills and avoiding common errors that make airway interventions less likely to be successful.
Ear-to-sternal-notch positioning Patient sitting upright with ear-to-sternal notch positioning. Known as back up, head elevated (BUHE) The ideal mask seal using a BVM. The index and middle fingers pull the mandible forward maintaining airway patency.
In this episode I discuss prehospital management of
traumatic cardiac arrest, broken into penetrating and blunt. In recent years
the pendulum has swung away from a nihilistic approach towards one that
maximizes outcomes in the highest number of patients. This requires taking a
standardized, aggressive approach when treating viable patients with traumatic arrest.
In penetrating traumatic arrest, addressing reversible causes based on the
location of the injury is essential. This primarily means hemorrhage control
and volume restoration (ideally with blood products). It may also mean chest
decompression (ideally with finger thoracostomy) for treatment of pneumothorax
or hemothorax.
In blunt arrest it is more difficult to determine an
underlying cause of arrest so a rehearsed, pre-planned “bundle” of care
directed at reversible causes should be delivered early. Chest compressions
should not be expected to be effective until volume is restored or tension
physiology is reversed. This approach is attributed by most people to Dr. John Hinds.
Primary interventions include:
Aggressive control of external hemorrhage.
Maintenance of airway and ensuring oxygenation,
ideally with intubation
Decompression of both sides of the chest,
ideally with finger thoracostomy but needle thoracostomy at minimum
Application of a pelvic binder
Reduction of all long bone fractures
References
Scott Weingart. EMCrit Podcast 135 – Trauma Thoughts with John Hinds. EMCrit Blog. Published on October 19, 2014. Accessed on May 24th 2019. Available at [https://emcrit.org/emcrit/trauma-thoughts-john-hinds/ ].
Traumatic cardiac arrest: a unique approach.
Harris T, Masud S, Lamond A, Abu-Habsa M.
Eur J Emerg Med. 2015 Apr;22(2):72-8. doi: 10.1097/MEJ.0000000000000180. Review.
Escutnaire J, Genin M, Babykina E, Dumont C, Javaudin F, Baert V, Mols P, Gräsner JT, Wiel E, Gueugniaud PY, Tazarourte K, Hubert H; on behalf GR-RéAC.
Resuscitation. 2018 Oct;131:48-54. doi: 10.1016/j.resuscitation.2018.07.032. Epub 2018 Jul 27.
Evans CC, Petersen A, Meier EN, et al. Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries. J Trauma Acute Care Surg. 2016;81(2):285–293. doi:10.1097/TA.0000000000001070
Hyperkalemia
Jul 22, 2019
Show notes
On this quick episode I discuss hyperkalemia, a life-threatening condition commonly missed by out-of-hospital providers. It is essential to recognize the signs and symptoms of hyperkalemia as these patients may require prompt treatment to prevent fatal dysrhythmias.
Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963–971. doi:10.5811/westjem.2017.6.33033
Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 2011;26(3):377–384. doi:10.1007/s00467-010-1699-3
Ryuge A, Nomura A, Shimizu H, Fujita Y. Warning: The ECG May Be Normal in Severe Hyperkalemia. Intern Med. 2017;56(16):2243–2244. doi:10.2169/internalmedicine.6895-15
Subtle hyperkalemia indicated by peaked T-waves and ST segment flattening in V3-V5 Hyperkalemia indicated primarily by peaked T-waves in V2-V4 Wide QRS and significantly peaked T-waves indicating hyperkalemia Substantially widened QRS with sine wave morphology indicating severe hyperkalemia
Severe Crashing Acute Pulmonary Edema (SCAPE) is a life threatening complication of heart failure. In this episode, I discuss the pathophysiology and modern treatment modalities with flight paramedic and medical student Michael Perlmutter.
References
Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719–723. doi:10.4103/0972-5229.195710
Hsieh YT, Lee TY, Kao JS, Hsu HL, Chong CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018;18(1):34–36. Published 2018 Feb 2. doi:10.1016/j.tjem.2018.01.004
Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Ann Emerg Med. 2007 Aug;50(2):144-52. Epub 2007 May 23
Paone S, Clarkson L, Sin B, Punnapuzha S. Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10.
Scott Weingart. EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE). EMCrit Blog. Published on April 25, 2009. Accessed on July 10th 2019. Available at https://emcrit.org/emcrit/scape/
IMAGE 2 – Pathophysiology of heart failure, Image from CORE EM
IMAGE 3 – Spiral of death in heart failure, Image from CrashingPatient.net
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