Case Presentation: A 70-year-old male presented to emergency room with 4 days of sharp chest pain and shortness of breath. Patient had a history of adenocarcinoma of lung and underwent VATS procedure 3 months ago. He had chronic pain since the procedure, however in the last 4 days, he felt progressively worse. His other past medical history includes essential hypertension and diastolic heart failure. On initial exam, it was reported that he was tachycardic with heart rate of 110 per minute, BP 100/50 mm Hg, respiratory rate of 34/ minute, temp of 100.4 f. He was showing signs of sepsis with elevated white count of 22000, lactate 14, and ABG showing anion gap metabolic acidosis with Ph of 7.1. Chest x-ray showed volume loss in left hemithorax, pleural opacities and new infiltrates suggestive of pneumonia. Sepsis protocol was initiated in ER and patient was given fluids and antibiotics. Patient got intubated due to impending respiratory failure and was transferred to ICU. However, on route from emergency room to ICU, patient became more hypotensive and was started on pressors. Careful rereview of chest X-ray was showing a globular heart and on exam, muffled heart sounds were noted along with elevated JVP.  An emergent bedside ECHO showed large pericardial effusion with signs of tamponade. Immediate pericardiocentesis was done and within few hours patients vitals improved. Cytology later proved malignant nature of effusion. Pericardial window was done and eventually patient recovered well. 

Discussion: Heuristics are defined as strategies that help to make quick decisions. Although they are of great help in daily practice, they often come with a price, in the form of heuristic errors. Physicians use heuristics on daily basis due to the numerous decisions they need to make in a limited time. The Representativeness heuristic error is the application of pattern recognition, a patient’s presentation fits a “typical” case; therefore, it must be that case. The availability heuristic error is placing particular weight on examples of things that come to mind easily, either because they are easily remembered or recently encountered.  With increasing focus on sepsis and its aggressive management in the emergency room alternative causes of shock are easily missed. As in our case, both the above-mentioned errors played a part in labelling the patient as septic shock. Our patient clearly had an x-ray evidence of source of infection, elevated white count, elevated lactate and hypotension suggestive of septic shock and sepsis protocol was initiated. However, he also had subtle signs of impending tamponade on imaging and clinical exam. Especially in the practice of hospital medicine it is important to not get carried away by the initial diagnosis from the emergency department and reevaluate the patient with no bias.  Any delay in the diagnosis would have been fatal. Fortunately, we had good outcome in this case.

Conclusions: The biggest hurdle in making right decisions is lack of awareness of the possible errors and biases in decision making. With increasing demands of hospitalist practice on day-to-day basis and time constraints, taking few minutes to reevaluate whether information is truly relevant, rather than simply easily available, is the key.