M&M - Dr. Bronner

Myocardial Infarction in TTP

1. Classic teaching for diagnosing TTP = "FAT  RN"
• F - Fever
• A - Microangiopathic Hemolytic Anemia (MAHA)
  
• T - Thrombocytopenia
• R - Renal Injury/Failure
• N - Neurologic Involvement
2. Newer thinking suggests you only need 2 of the above for a CLINICAL DIAGNOSIS
• MAHA and Thrombocytopenia 
  
• Peripheral Smear with schistocytes also helpful!
3. Important to Dx early because treatment is best when started earliest - Plasma Exchange 
• Call your hematologist early!
4. What about the heart?
• Lots of case reports, but few studies... suggest 15-40% of acute TTP have myocardial ischemia
• If you suspect TTP get EKG, enzymes (TnI is best), and place patient on telemetry.
5. FEVER is more suggestive of infection - THINK sepsis and DIC
6. Consider revising your mnemonic... CAT RN
• C - Cardiac Involvement
• A - MAHA
• T - Thrombocytopenia
• R - Renal Injury
• N - Neurologic Involvement

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Penetrating Scrotal Trauma:

1. What should we try to repair in the ED?
• Only superficial wounds!
• Anything that penetrated Dartos Fascia needs to be seen by urology
• High incidence of damage to other testicle and cord structures

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Diagnotic Error in Medical Decision Making

1. Two of the major types of Error in our Clinical Thinking
• AFFECTIVE - The notion that we may treat a patient differently because there is something about them or about the circumstance that evokes either a negative emotion or a positive emotion…
• COGNITIVE - Errors based in problems with our analytical thinking... 
  
2. Work to be aware of "Cognitive Dispositions"... Multifaceted, but two we deal with in EM regularly
• COGNITIVE TRANSFER - Clinicians “pass off” biases when transferring the care of a patient to someone else.
• DIAGNOSTIC MOMENTUM - Once the patient is given a diagnosis, it becomes difficult to remove. The diagnosis is then passed from provider, to provider, to provider…
3. "Cognitive Forcing Strategies" can be employed to avoid these pitfalls, for example:
• DIAGNOSTIC PAUSE - Was I comprehensive? Is there something I haven’t considered? What is the worst case scenario?Was my judgment affected by bias(es)?
4. Many thanks to Dr, Michael Gibbs for his excellent slides on this topic... for more on metacognition in medicine check out Pat Croskerry's multiple works on the topic.  Here's a sample .mp3 from the NEJM.