Blog & Articles

A chief complaint of pain is one of the most common encountered by practitioners in any specialty. The pain may be acute or chronic. It may be located in the abdomen, chest, head or any other body part. It may be spontaneous in onset or may be due to an injury. It can range from minimal discomfort to a 15 on the pain scale of 1 to 10. The seriousness of the pain may vary from life-threatening to embarrassingly minor.The patient’s description of pain may be pinpointed and exact or agonizingly vague. Regardless of its characteristics, pain is what brings patients to healthcare providers by the millions every year.

Many diagnostic errors involve some degree of cognitive bias or errors; here is an actual case that illustrates this point.

Case Presentation

L.B. is a 46-year-old man with onset of illness 12 days prior that started with cold symptoms, sore throat, rhinorrhea, cough, and fever up to 100.7°F (38.1°C). Since then, he has been getting progressively weaker, to the point that he could not walk to the EMS vehicle.

Failure to diagnose is the most common medical error in the practice of emergency, urgent care and primary care medicine. Spinal epidural abscess (SEA) is one of the most difficult conditions to diagnose, but there are common threads among failure to diagnose spinal epidural abscess cases. This case is presented to provide perspective and to increase our vigilance for catching this disabling and possibly even fatal diagnosis.

The discoverer of penicillin, Sir Alexander Fleming, warned many decades ago that the “public will demand [the drug and]…then will begin an era…of abuses.” His prophecy has been realized, and I readily confess that I am guilty. During my 37 years in family practice and emergency medicine, I admit that I prescribed antibiotics for viral and self-limited illnesses. There were times when I bowed to pressure from ill and desperate (but not desperately ill) patients or their parents who demanded a cure for an upper respiratory infection.

There is a new risk and safety issue in the world of appendicitis. In this issue of TSG Quarterly, we explore the issue of conservative, antibiotic-first management of acute appendicitis with appendectomy reserved for treatment failures. Is it the new standard? Have you proactively addressed this issue with your emergency medicine and surgical practitioners? It is important to get out in front of this issue to keep our patients safe!

Not all chest pain is a heart attack. While acute coronary syndrome (ACS) may be the most common serious cause of chest pain, clinicians must keep other dangerous conditions in the differential diagnosis and eliminate the possibilities based on the patient’s history, risk stratification, physical exam and diagnostic testing. One of the most dramatic and perplexing causes for acute chest pain, other than ACS, is thoracic aortic dissection.

Preventable hospital readmissions cost taxpayers billions of dollars each year. As we move further into the age of healthcare reform, practitioners will feel rising pressure to reduce costs and decrease unnecessary and preventable re-hospitalizations.

Providers cannot and should not avoid the readmission of patients when medical or surgical situations require inpatient care. However, a fair percentage of unintended readmissions can and will be reduced by implementation of initiatives that not only improve quality, but support patients as they transition through the care continuum.

It is certainly a good idea to avoid readmissions that are deemed unnecessary. However, from the vantage point of risk and patient safety, the sword of readmissions reduction has another sharp and dangerous edge. Plain and simple, along with sensible system solutions, there will be irrational but powerful pressures exerted on the gatekeepers of inpatient admission to send sick patients home rather than readmit them.

Healthcare is all abuzz about evidence-based medicine (EBM), and legions of clinicians are struggling with how to incorporate EBM into the new paradigm of providing the safest possible high-quality healthcare in the most efficient manner.