Things are further complicated by confounders, mimics and the disjunction of concern.

Confounders are concurrent pathologic processes that the patient already has, which tend to get worse due to any new significant disease process or general body stress. CHF and COPD get exacerbated, kidneys become insufficient, anxiety and psychoses go florid and atrial fibrillation accelerates to rapid. How do you spot sepsis or an MI, which is the true cause of it all, underneath layers and layers of abnormal vitals and test results?

Mimics are things that pretend to be other diseases. PE presenting with a low-grade fever and a cough, carbon monoxide poisoning posing as geriatric altered mental status, and severe sepsis arriving as chest pain, dizziness and a bumped troponin. Such has happened many times in the past and continues to happen daily at all EDs globally.

The disjunction of concern is when your patient is not worried about what you are worried about. They don’t want to get cancer like their neighbor, but they have never heard of a TIA or an AAA. Kawasaki disease? Why don’t you just give my daughter better antibiotics? My uncle died of a heart attack at 35, not a “bisection” or whatever you called it…So I don’t want a CT scan!

An EM physician’s focus on ruling out worst-case scenarios may paradoxically contribute to a patient’s distrust at the end of the encounter. The patient’s agenda is to leave knowing what disease they have, while we are often satisfied knowing which horrible things a patient does do not have.