The Art of Observation

I am a Senior House Officer (Registrar in NZ) in General Medicine. I get called down to ED for a diabetic patient who is in "DKA". I walk into the resuscitation room where a large man is lying flat on his back unconcious. The attending ED SHO is actually a former classmate from medical school. A very clever student who would usually have a high ranking in exams. My classmate is busy doing some notes in a corner of the room. Before I lay a hand on the patient I notice he is only breathing at a rate of 4 breaths per minute. This is odd I thought. In DKA tachypnoea if anything would be expected. He is unrousable. I first check his pupils- they are pinpoint. I call for immediate IV naloxone and he wakes up. He was in DKA due to a pneumonia but he was also critically respiratory depressed from an unintentional OD of opiates he had been taking for back pain.

I am a post MRCP Medical Registrar at a base hospital in NZ. I am called to ED by a senior doctor for a patient who is in "acute LVF". As I walk into resus ED doctors are giving the patient IV frusemide and a nitrate infusion and oxygen. From the other side of the room I can see that he is not diaphoretic. Unusual I thought. He should be sweaty. Getting closer to the patient I can hear that he has mild stridor. I turn to look at the CXR film which is on the Xray box (yes there did used to be such things!) on the other side of the room. Even from here I can see that the cardiac size is normal, there is no pulmonary oedema and that there is an obvious superior mediastinal mass causing tracheal compression. The ED doctors cannot believe the diagnosis and rush over to look at the CXR. I stop the anti-failure treatment and transfer him to the regional cardiothoracic team.

I am doing an ED Registrar night shift at a base hospital in NZ. I am working with a senior ED doctor a consultant in their own country. I find myself in an unusual position of technically being "supervised" by a younger and much less experienced doctor than myself. An elderly man comes in with severe abdominal pain and haematuria. He has been given a significant amount of opiates by the paramedics and also by my colleague. He is basically in clot retention. I insert a catheter which relieves his pain but his haematuria continues. We notice that he has become hypotensive. My colleague becomes convinced that the patient is bleeding out from some form of atraumatic renal haemorrhage and wants to start resuscitating him. The patient is not tachycardic, he is not cold/sweaty and he is mentating normally and actually looks relatively well. I've seen plenty of cases of bad haematuria in my time but have never seen anyone bleed out from non-traumatic causes. My first thought is that it's probably the opiates. My colleague insists on giving him a fluids. No response. I politely hint that we could try naloxone. Fortunately my colleague agrees and his hypotension resolves with naloxone.

I arrive at a teaching hospital ED to do my day shift in Paeds ED. I take a handover from my exhausted junior Registrar colleague who has just done the busy night shift. He tells me about a 10 year old boy who has "asthma" who hasn't really responded to treatment. I tell him not to worry and to get off home. From my seat at the nurses station I can hear this boy having quite loud stridor. He hasn't responded to asthma meds because he doesn't have asthma. I request a CXR which shows obvious tracheal compression from a mediastinal mass. I arrange transfer to the regional PICU. Nice to see that the supervising ED consultant had his finger on the pulse of the department!

The point of these cases is not to promote myself. These were not difficult diagnoses to make. The point here is to emphasise the importance of basic observation and being present.

There were several other factors at play in these situations—tiredness, lack of experience, cognitive biases and ego. We will come back to the topic of cognitive bias at a later stage.

Often in emergency situations doctors ignore basic things—they feel a pressure to act quickly, take action, appear confident. Sometimes the best thing to do is just stand back for a few seconds and assess the situation.

Learning Nuggets

• The assessment of the patient starts before you meet them— its starts as they walk past you into triage, as you hear them from the doctors office, as you see them in the waiting room, as you call them from the waiting room. Practice the art of observation.
• Fatigue and cognitive load impair perception. Tiredness, busy environments, and shift work reduce situational awareness and increase reliance on heuristics and handover diagnoses.
• Premature diagnostic closure is common in emergencies. Once a diagnosis is named, teams tend to treat the label rather than the patient. This momentum is hard to reverse unless someone consciously challenges it.
• A short pause can prevent major error. Taking a few seconds to stand back and reassess can completely change management and prevent harm.
• If the physiology doesn’t fit the label, stop. DKA without tachypnoea, LVF without diaphoresis, haemorrhage without shock physiology, asthma without wheeze—these should all trigger diagnostic reassessment.
• Listen to gut feelings. These are complex judgements based on experience and intuition. When something doesn't seem right you will often be right.
• Experience often shows itself as restraint. Senior clinical judgement is frequently expressed not by acting faster, but by knowing when to pause, observe, and reconsider.
• Make your own diagnosis.
• Opiates are a common, often unappreciated cause of hypotension.