Case Presentation: Our patient is a 64 year old gentleman with a history of prior cerebellar stroke who presented to the Emergency Department (ED) after being found unresponsive in his car by bystanders. On ED evaluation he was noted to be lethargic, able to follow commands but unable to recall what happened. Neurologic exam in the ED did not demonstrate focal neurologic deficits. He had endorsed drug use to first responders, but had denied drug use in the ED. He confessed to the overnight team that he had smoked tobacco rolled in ecstasy, followed by ingestion of 1 cup of rubbing alcohol. CT of the head was negative for acute intracranial abnormality. Urine drug screen was negative. Labs were otherwise within normal limits. He was admitted to the hospital with the diagnosis of drug overdose. On evaluation the next morning, he continued to be somnolent, confused and inconsistently following commands. He continued to have no focal neurological deficits. A telephone call with a friend clarified that the patient had called her on the night of admission prior to his ED stay saying that “[he] had gone blind”. In light of this new information, his vision was reassessed confirming reactive pupils but no reflexive blinking to visual threat. The patient continued to deny vision problems. MRI of the brain showed numerous acute/early subacute ischemic infarctions in the left cerebellar PICA territory, bilateral occipital lobes, hippocampi, and bilateral thalami. CTA of the head and neck demonstrated a filling defect within the aortic arch concerning for thromboembolic disease. He was subsequently transferred to the neurological ICU for further management of his cortical blindness secondary to thromboembolic stroke.
Discussion: This gentleman was initially diagnosed with a drug overdose but actually suffered an acute stroke causing cortical blindness. Although his urine drug screen was normal and he had a recent history of stroke, his atypical presentation paired with a reported drug abuse history resulted in implicit biases regarding his social history contributing to persistent anchoring bias that delayed care.
Conclusions: Implicit biases not only exist in medical practice but also play a role in healthcare disparities. These biases occur without conscious awareness and are often at odds with a professionalʼs personal beliefs. Although these biases exist, there are no standardized requirements for discussion of implicit biases within medical education. In the interim, biases continue to contribute to inequities in patient care. This case details an example of how implicit biases associated with substance use contributed to anchoring bias in a crucial clinical setting. Promoting awareness of the very real consequences of implicit biases on healthcare outcomes can aid in creating a more equitable healthcare environment.