Cite this post as:
Scott Weingart, MD FCCM. EMCrit 293 – The Jerk & Check, Functional Heuristics in Resuscitation Project (MotR). EMCrit Blog. Published on March 3, 2021. Accessed on June 9th 2023. Available at [https://emcrit.org/emcrit/functional-heuristics-in-resuscitation/ ].
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
Original Release: March 3, 2021
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Go to epi early This was advice I got from a senior anesthesia resident advising me early on in my training, when dealing with hypotension. Obviously, I would caution you to know your patient before starting epinephrine. Treating hypovolemia with epi is a bad move. Treating HCOM with epi is a bad move. Treating an arrhythmia with epi may be a bad move. But, in general, remembering that when I’m not sure why a patient is hypotensive, to consider a drug with inotrope, chronotropy, and vasocontriction, is generally a good place to start my thinking. Equipoise exists between Epi and… Read more »
I was giving anesthesia for a pt undergoing laparotomy and bowel resection. Pt is getting progressively hypoxemic. ETCO2 curve looks fine, airway pressures OK, I listen to the chest (which I think I’ve done once of twice in 30 years of doing anesthesia), it’s clear, I finally bronch the patient, and that’s fine. All the while the case is going on. I have no idea what’s happening. The patient starts getting a little hypotensive. I don’t know what to do. I finally start an epinephrine drip. The heuristic is, when all else fails, start epi. The patient starts turning around… Read more »
Constipation is not an ED diagnosis for the elderly abdo pain. Up there with the costochondritis/gastro list.
From Greg Henry; “If your discharge diagnosis is the same as your presenting complaint you have done nothing for your patient”
From Bob Wears; are there any signs/symptoms which are outliers from your working diagnosis and are they red-flags for a must-not-miss-diagnosis.
Runs directly counter to the ‘no costochrondritis or gastro’ one.
If a patient states a relative that just recently died is “calling to them to join them”, work hard to make sure they are not correct.
I used the “erad #1” all of the time when I was NYC medic 30 years ago. Lifting the head with my right hand, after visualization, I used my knee or anything I could find when intubating on the floor to hold the head in position or a pile of sheets or blankets when in the ambulance. Rarely needed neck pressure. Manipulating the head with the right hand and the blade “near” the vallecula. It worked!
Here is my heuristics,
1. stroke symptom with hypotension → AAD going into brachiocephalic artery or cardiac embolism from very low EF left ventricle, do US of Ao/neck artery and heart
2. acute hypotension and tachycardia with ST elevation or negative T on ECG monitor after severe physical stress (leading to possible endogenous catecholamine surge)→ Takotsubo cardiomyopathy, check 12 leads ECG and TTE
3. young female with altered mental status or convulsion → anti-NMDA receptor encephalitis, check teratoma
How do you think?
UTIs in the elderly do not cause altered mental status.
Too many times family members will say “Grandma has a UTI again, because she’s confused.” Maybe, but I’ve seen a few bad outcomes when we anchor on that.
To turn this into a heuristic, mine is “In the confused elderly patient: It’s always a UTI, it’s never just a UTI.”
Scott, there is so much good stuff to unpack in this! Just to validate and opine. I do not interpret Kahneman and Taversky to view system 1 as the source for bias and system 2 as the source for corrections. I view their thinking as that both of these models for decision-making exist within us, and they have their relative strengths. Maybe I misunderstood your intention. In economics, we are taken advantage of in certain circumstances when we only use system 1 (Vegas) but we are humans not perfect automatons, so it’s just best that we are aware of the… Read more »
great stuff!!! Kahneman was pretty clear about System 1 being a source of bias. Hence his arguments with Gary Klein on this exact topic. You can hear our interview of him here: https://emcrit.org/emcrit/decision-making-gary-klein/
Sudden altered mentation including combativeness, check glucose
“If your patient is diaphoretic, you should be diaphoretic.” I can’t remember where I heard this, but it has served me well. When you just aren’t sure what is going on, unexplained diaphoresis should make your feelers go up as it may be a sign of a catecholamine response to a life-threatening issue. I remember a patient with a pretty classic migraine-type headache that was strangely diaphoretic who turned out to have a vertebral artery dissection, and another unexplainably diaphoretic individual who just didn’t look quite right. However, you couldn’t really put your finger on it (heart rate and respiratory… Read more »
This is a general Heuristic: When considering an atypical presentation of a potentially life or functional status threatening diagnosis (TIA, Stroke, dissection etc) in a high risk patient (for example a patient with CVD risks) you must not settle for anything except the most sensitive available exclusionary test (MRI/MRA brain, CTA chest) OR a very highly specific test to confirm an alternative diagnosis. You need to definitively rule out the proposed diagnosis Or definitively rule in the alternative. Don’t rely on weaker evidence. In Bayesian terms, you start in mid range probability for the life threatening process (high risk profile… Read more »
If your sick patient says they want to open their bowels you’d better get ready to start CPR.
Along the lines of costochondritis and gastroenteritis… “colic” is not a diagnosis in the ED. Got to think occult infection, occult injury NAI, and a slew of other medical and social/family processes.
Jerk: Significant Respiratory distress -> Non-invasive ventilation
Check: Lung US (or rapid CXR…don’t @ me) to confirm no pneumothorax- since pneumothorax is essentially the only big contraindication to NIV in this patient
Jerk: Short of breath and significantly hypertensive -> NIV and nitro push
Check: Lung US for B-lines as the NTG is being drawn up/started
Persistent vertigo is posterior stroke until proven otherwhise
New onset generalized seizure is cardiac arrest until you check the pulse
This one is for pharmacists but is also relevant to nursing and medical providers. Jerk; If you’re grabbing more than two vials (or tablets etc) you have the wrong dose Check; Drugs are usually produced such that 1-2 doses should be all a patient needs in normal circumstances. If you need 5 vials that should prompt you to verify with a reference, coworker, or pharmacist that you indeed have the correct dose or that special circumstances warrant your deviation from usually dosing. Obvious exception; four 81 mg chewable ASA Many reported medication errors, some fatal, would be easily have been… Read more »
Would it be fair to say that this pub (Evans CS, Slovis C. Revisiting the Ten Commandments of Emergency Medicine: A Resident’s Perspective. Ann Emerg Med. 2021 Mar;77(3):367-370. doi: 10.1016/j.annemergmed.2020.10.013.) is basically a list of the author’s functional heuristics?
If there is sudden resolution of swelling in blue leg from DVT, think of pulmonary embolism or pulmonary embolism about to crash the patient.
My mnemonic for Traumatic Arrest which also highlights priorities:
Stop the F***ing Bleeding.
S – Stop bleeding
T – Tube patient
F – Finger both sides of chest
B – give Blood
Great podcast. It would be interesting to consider function heuristics in paramedical practice, pre hospital environment.
Is this a heuristic?
A bit late to the party and appropriately, this is my ‘glass of wine test’.
I project myself to sitting down after the shift with a glass of wine. If I think that at that point I would be reflecting on (insert action) with angst that I could have done, then maybe just do it now.
Luckily I have very rapid memory delete all, so this rarely happens.
more of a life rule–but a good one!
Hey Scott! One that stuck with me from your podcast: (1) Vent alarm = Code blue. Otherwise: (2) Tube placement confirmed–> cycle BP. and finally (3) Transcutaneous pacing–> confirm mechanical capture with SPO2 waveforms and/or ultrasound if available
great stuff. those fit more in the ERAD realm, but good to remember all of them