First Impression Biases

Heather Jiménez, MD

Disclosures

January 22, 2009

In the emergency department, first impressions are often harsh and difficult to overcome. In seeing people at their worst, I worry I get a skewed picture of who they truly are outside their crisis. The initial snapshot in time during the history and physical exam determines what pathway, if any, is pursued for the patient. Any biases I encounter must first be recognized and then closely kept in check to ensure that a negative first impression does not lead to increased morbidity or mortality for the patient. A single encounter reinforced this for me, and luck helped prevent complications for my patient.

On a busy overnight shift, I encountered perhaps my least favorite complaint – two belly pains in a row – and no sign that anyone else was going to split them with me as we were all very busy. The first was pleasant, gracious and easily evaluated. Moving into the second room, my system encountered a shock. Before even introducing myself to the patient (who was still fully dressed with a cigarette over each ear), she stopped her conversation with her husband to relay her wishes, "what pain medication are you going to give me to take home and how much? We have no money so you are going to have to provide it from here," - so much for my standard introduction.

Taking a second to regroup, I introduced myself and was interrupted with the same question again. Both frustrated and annoyed, I did not even know what the patient's concern was as the focus was on narcotics. Trying a different approach, I assured the woman we would treat her pain, but I had to get some information first. With much difficulty, I managed to gather that this patient had pain everywhere in her abdomen for a while, had a previous tubal ligation so she could not possibly be pregnant, and wanted something to eat and drink – could I get that for her. With my biases and opinion fully formed, I then attempted a fairly unsuccessful physical exam which was hindered by her inability to cooperate. Explaining that I would be back to do a pelvic exam, I left the room angry with the patient because she would not cooperate and had a seemingly single focus.

Ordering a urinalysis and UPT more because it was reflex than thought, I also included some IV pain medication in my initial plan so I could get a decent exam, or at least try again. With stable vitals and my initial impression, I wrote her off as "not sick" and a potential drug seeker. My first step when staffing though, was to look the patient up in the computer – she was not a frequenter of any system on the summary sheet, but her behavior did not sit well. I even entertained the idea that her husband put her up to this as she had not had any controlled scripts filled in the Indianapolis area and was very blunt about her wish for narcotics.

While awaiting the results, I encountered my patient roaming the hall several times asking different employees for food and drink. Becoming even more frustrated, I began digging regularly through the order pile so I could quickly get her out of the department as soon as her urine studies returned.

Then my plans were turned upside-down. The UPT was positive. Finding a staff and wheeling the ultrasound machine into the room, I had to explain to the patient, who was still hungry, thirsty and ready to leave, that she was pregnant. With a prior tubal ligation, this was a potential problem. Immediately, her husband understood my concerns, but the patient was now overjoyed and talking about a new baby. Regardless of what I said, she did not understand that there was a possibility this pregnancy would not go to term and that it could potentially kill her.

Feeling guilty that I had written this woman off, as well as concerned that she could have a potentially life-threatening ectopic pregnancy, I proceeded with the remainder of my exam. Breathing a sigh of relief, the ultrasound showed a sac in the uterus with no heartbeat or fetal pole. In my mind, I was preparing to have the patient follow up with OB in 48 hours when I saw the free fluid and what might be a clot behind her uterus. A FAST exam did not give any more information except for confirming suprapubic free fluid.

While awaiting labs, I contemplated the roller coaster I had taken this couple through, as well as the initial biases that shaped my opinion of the patient. Gone was her desire for narcotics as she planned her future with another child and her excitement of this unexpected event. Raw was her husband's emotion and his understanding that this was likely not going to end happily. And then there was my own guilt that I had brushed this patient off as not sick because of our initial interaction. Yes, I had given her pain medication and ordered the UPT and urinalysis, but in my mind I had mis-stepped in my hastily formed opinion.

After several hours of stability in the ED and still no labs, I convinced the OB resident to examine the patient. Still wandering the halls and demanding food, the patient went upstairs. The operating report available the next day indicated that the free fluid behind her uterus was blood from a ruptured ectopic and both her tubes had to be removed to prevent a repeat tubal pregnancy in the future. There was no mention of the sac or potential follow up for what had appeared to be an intrauterine early pregnancy.

Though sheer luck and habit allowed me to catch this, it still made me think. I could have sent this patient home for 48 hour follow up, and if I did, she might have died. I could have missed the pregnancy all together as I was focused on her narcotics concern instead of her presenting complaint. I could have missed seeing the side of her that was overjoyed at the potential of having another child – the side that I suspect is who she really is much of the time.

Although it is only human to form biases and opinions, this patient reinforced the need to approach every patient with an open mind and focus on how I can improve each patient's life and help them through their crisis.

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