Itâ€™s important to be wrong now and then. Not just for the usual blather about being humble, understanding cognitive biases, or even nailing the Kobayashi-Maru test.



No, it’s important to be wrong in the right sort of way, a willingness to be humble in the interest of patient care. Let me explain!

Case #1: I was sooo right.

EMS brought in a middle-aged male who was â€œfound on the floor,â€ having been their for an unknown period of time. Their medical history and medications were also unknown, and his altered mental status didnâ€™t help. Vital signs were okay, although the heart rate was unexpectedly low for someone who looked sick and dehydrated. While my resident was examining the patient, I talked with Sara, the paramedic, about the ECG.

â€œHuh,â€ I said to Sara, â€œfunny itâ€™s so slow, since he looks dry as dust. T-waves also look a bit funky â€“ I wonder about hyperkalemia. Hey, don’t be afraid to empirically treat if the history and ECG make you suspicious.â€

We grabbed our own ECG in the ED:



This was also supportive of hyperkalemia, and so I pushed calcium before waiting for the lab results. The potassium turned out to be.Â #Â #

Case #2: Â #OrWhat

An elderly female with no prior ECGs, or records of any sort, was brought in by EMS with a report of â€œaltered mental status.â€ She actually seemed mostly okay to me, but the veteran paramedic, Chris Lovell from Norwalk, showed me the ECG:

“Now, I know what you’re thinking…” Yeah, it was paced, so some of you might say â€œyou canâ€™t tell anything from the ECG.â€ Probably should have listened to you! Two points in my defense however:

First, there are a number of case reports of hyperkalemia manifesting in paced rhythms. See here, here, and here, for example.

TL;DR? You might see loss of pacer capture, or significant QRS widening compared with an old ECG. Some of the better examples:

Second, did I mention I have Jedi-like skills in detecting hyperkalemia?



I proceeded to personally push 3 grams of calcium gluconate, and rechecked the ECG to document my â€œwin.â€No changes whatsoever. The potassium was completely normal.

Okay, so I was wrong. But was it a capital-F â€œFail?â€ (Of course, my short answer is â€œNo.â€)

Hereâ€™s the longer answer why this was NOT a fail.

If an ER doctor tells you, with pride, that their accuracy in diagnosing STEMI is 100%, since they have never sent a â€œfalse-STEMIâ€ to the cath lab, then they are either (best-case scenario) lying, or they are (worst-case scenario) very bad at their job.

If you never send a â€œfalse-STEMIâ€ to the cath lab, it means that you are probably NOT picking up on a bunch of â€œtrue-STEMIs.â€ If you arenâ€™t taking a chance on the small or subtle STEMIs, then you might be hurting patients.

The surgeons have understood this about appendicitis for generations. At least before CT scans started being used, a good surgeon was defined by the number of â€œnegativeâ€ appendectomies you performed:

Too many meant you were too quick to cut, and had no sense of clinical judgment.

meant you were too quick to cut, and had no sense of clinical judgment. Too few meant you were missing â€œtrue cases,â€ letting them perforate & get septic.

We could view empiric treatment of hyperkalemia like that â€“ if you arenâ€™t overtreating at least sometimes, then you are probably missing critical chances to treat a potentially lethal condition. And unlike going to the OR or the cath lab, the EMS therapy (calcium chloride) is pretty benign.

So perhaps we should take pride in over-reacting (within your guidelines and protocols, of course). Maybe we could start to track our â€œnegative-Kâ€ rates, and even start to brag about them!