Trusting your gut, hand-off bias, and building your 'why's'

I was a second-year resident on my pediatric emergency medicine month. I had worked enough shifts to become comfortable with the duties, the nurses, and the attendings. I listened to the attending take a radio call and was told they were “bringing in an 8-year-old who is playing possum,” implying that the child was faking an unresponsive state. 

Though comfortable walking into any room by this point, I still experienced some anxiety while waiting for a patient arriving via ambulance. Not knowing what would roll in, exactly, along with my catastrophizing imagination, always seemed to put me on edge, given time.  But on this occasion, I was reassured it would be non-urgent. I was feeling confident and at ease.  As the paramedics rolled in, I saw an 8-year-old girl with a braid lying on the gurney with her head to one side being very still. I walked toward them to show them in which bay to place her.  The one paramedic said, “I think someone didn’t want to go to school today.” We all chuckled. I walked beside the foot of the bed as we headed toward the bay.

Some force between an instinct and gut sensation caused me to reach out and rapidly flex her left foot into dorsiflexion; the response was sustained clonus. Surprised, I looked back at the paramedics and said, “I’ve never seen that in someone pretending.” They shrugged and left to finish their paperwork. I quickly notified the attending as the nurses started hooking her up to the monitors and getting vitals. We confirmed her abnormal lateralizing neuro deficits. Her mom appeared as we sent the patient for a CT scan. The attending left to allow me to update her and get more history. The mother was relieved to see we were taking the patient’s state seriously; she wasn’t so keen on the paramedics’ assumption. The mom had been in the bathroom finishing the braid when her daughter went limp and fell on the floor. There were no sustained rhythmic movements or loss of bladder or bowel function. The patient didn’t say anything before going down. There was nothing unusual about her health the last few days. The ED was unusually slow that day, so I sat and chatted with the mom until the patient was back from radiology. The CT scan confirmed a significant thrombotic stroke. During her long admission, she was diagnosed with lupus, and this was the first manifestation. I went up and visited them a few times during their stay as the child had regained consciousness and was silly and giggly – a bright spot in my day.  She regained much of her neurologic function before discharge.

Two lessons I took from that experience – one is whenever you feel that hunch-driven urge, act on it.  Divine intervention, medical intuition, sixth sense – whatever you term it – it’s always served me well to act on it.  A handful of times in my career, it’s been incredibly helpful and occasionally life-altering for the patient.  The second is that bias is sneaky.  I had totally bought into the paramedics’ story of how this little girl was faking.  I don’t think the outcome in this patient’s case would have changed had I not oddly checked for clonus as we rolled into the bay, but it was an important lesson. Throughout training and afterward, I have always tried to approach every patient from a clean slate in my history, physical, and assessment. Doing so avoids having a handoff bias, building a plan on an incorrect assumption, and missing important items.

About a month later, I was paged overhead at the main hospital.  I was told there was someone in the lobby there to see me.  When I arrived, I saw an 8-year-old with a braid and a big smile standing beside her mom. She had drawn a picture to give me of herself and me with a sun in the sky. We both had big smiles.  Her mom had a polaroid camera and snapped two photos of us, one for each of us.  The picture and the photo hold a special place in my photo album – and were among the firsts added to my list of “why’s.” This is a great practice to get in early in your career.  

So, trust your gut, build your own assessment, connect with your patients, and write your “why’s.” On down days, when you’re rethinking your calling, look at them as reminders. You are right where you are supposed to be.

Have a joy-filled day -Tonya

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