A 36-year old-white female originally presented to the emergency department (ED) per ambulance as a trauma patient after being found down earlier that evening at home. Initial Glasgow Coma Scale (GCS) score was seven, and she was rapidly intubated. A computed tomography (CT) trauma scan of her chest revealed a high density consolidation in the posteriomedial right lung base that was initially interpreted as “a likely contusion in the setting of trauma”. However, there had been no mechanism of injury that would have led to a pulmonary contusion. After being deemed “stable” from a trauma standpoint, care was transitioned to critical care medicine. Within twelve hours, sputum and blood cultures grew gram positive cocci, and patient had an elevated pro-calcitonin level. Both cultures were later identified to be Streptococcus pneumonia. The first dose of antibiotics was given several hours after presenting to the ED trauma bay. This was secondary to lower index of suspicion for sepsis by both care teams in this young patient who presented as a “trauma” patient.
Heuristics are cognitive processes involving mental shortcuts that serve to simplify decision making and are viewed as economical and resourceful when successful. However, when they lead physicians astray, they are termed cognitive biases. This case represents perfect examples of availability bias (in which people judge likelihood by how easily examples come to mind), anchoring bias (sticking with initial impressions), framing effects (making different decisions depending on how the information is presented), and premature closure (settling on a diagnosis before all the evidence has been presented). Availability bias and premature closure are responsible for the majority of ill-fated clinical decisions. The initial presentation of this being a “trauma” patient lead to the availability bias by the radiologist and trauma team of concluding that the consolidation on the trauma scan was a contusion. This precipitated the other biases that primarily impacted the critical care medicine team. When new diagnostic information is not incorporated into the decision making process because of a powerful anchoring effect from the presumed diagnosis of one physician, this becomes a dangerous situation and can be fatal to patients. Becoming aware of these errors and biases might lead to sustained improvement in patient care and outcomes.
This vignette highlights an incident of physician bias due to the initial patient presentation and reiterates the importance of always approaching every patient with a broad differential diagnosis. Multiple physician biases were present and were carried through the transition of care from trauma to critical care. Becoming aware of common cognitive errors and revisiting the broad differential helps ensure a proper medical evaluation, and in this case may have resulted in a more timely diagnosis of sepsis and antibiotic administration.