Sorting out Gabrahat (Anxiety) ~ The Common Complaint in the ED

 Gabrahat (Anxiety) is often a common complaint with many implications.

While working in Emergency Departments in India I have been surprised with what the ultimate diagnosis was when I investigated Gabrahat.

For me Gabrahat is as vague as the Horizon and I take this complaint very seriously. It is very easy for any Nurse or Emergency Physician to get framed and just label Gabrahat as Anxiety or Hysteria.

This can be the Epic Blunder of Large Proportions. 

Many times relatives who accompany the patient will Frame the Emergency Physician by saying words like “There is Tension”. What they mean to imply is Gabarahat is Stress Related.

I often relate Gabrahat to a “SENSE OF IMPENDING DOOM”. When you grade GABRAHAT in that perspective, it guides the Emergency Physician to be very Proactive and diligent.

Let me share a few blasts from the past which I have modified for the sake of Education.

Case One:

Middle Age Female comes to the ED saying that she is feeling SOB. She is hyperventilating and Diaphoretic. She says that she has been having pain all over the body and fells GABRAHAT as if something is going to happen to her.

Her vitals are stable but she continues to breathe hard and breath fast. The relatives were doing a Fine job of Framing her as hysteria.

Rapid Fire Questionnaire Labs EKG Trop and a X-ray Beta HCG UA and a BNP are ordered.

On examining the patient the only Finding is the breathing. Lorazepam given IV and Oxygen started and ABG Ordered which is showing alkalosis. Aspirin given and a bedside Glucose is Normal. She settles down but continues to breathe hard. A CTA Chest is ordered. 

There are massive shower Pulmonary Emboli. Pt gets thrombolyzed and goes to ICU.

Case Two:

A 55-year-old women comes with GABRAHAT. She says that she is afraid something is going to happen. She has no other symptom. She has no Past Psyc Issues.

Labs EKG Trop and an X-ray UA ordered. She has had a prior hysterectomy.

She had an ST Elevation MI. Went to the Cath Lab. No Symptoms at all. No Past History at all.

Case Three:

30-Year-old man came saying He had Gabrahat and felt that there was Irritation in the Chest. NO PAIN BUT ONLY IRRITATION. Exam Past History negative.

Cardiac labs CBC RFT LFT was negative so was his EKG and Xray. Against the will of the Internal Medicine Colleagues Pt admitted. 4 hour repeat EKG and Trop was placed from the ED. His EKG was normal but his Trop had become positive.

Cardiology who scheduled the patient for a cath after admitting him to CCU found a Tight Lcx Lesion which needed a Stent.

Case Four:

48 Female with Gabrahat. Second visit after discharge from the hospital. Come back saying she is afraid. No Pain, No Focus of Infection. 

CBC RFT LFT Cardiac Labs X-ray Beta HCG and UA Negative.

Says her Mind tell her Something is wrong. She has GABRAHAT.

Was admitted in a nursing home. CBC Electrolytes creatinine and SGPT was done and after overnight IV Fluids patients sent home. A CT Head done and the patient had SAH. No Neck stiffness no Eye signs. Admitted to Neurosciences ICU

The only thing that prompted a CT Head was “My Mind is telling Me. This was perceived as Hallucinations hence CT Head Ordered.

Case Five:

18 Year Old Male comes with Gabrahat with Hallucinations. He was at friends party and says “ I have gabrahat as I see a ghost”.

Tox Work up was done and it was positive for multiple substances.

Routine CBC RFT LFT EKG Trop UA and Xray with a CT Head and Tox Screen were done.

Case Six:

40 year old male comes saying that he has Gabrahat and he feels like a huge Log of wood just fell on his head and nailed his whole body vertically into the ground. Clinical Exam and Vitals were normal.

CBC LFT RFT Trop EKG Xray negative

No Neck stiffness Neuro exam normal. He kept saying I am afraid I am sinking into the ground.

CTA Aortagram ordered: He had a dissection from Thorax to iliac bifurcation.

Admitted to CVTS Sx.

Summary:

• Basic Approach should be T/P/R/BP/Pulse Ox
• I always order a CBC LFT RFT EKG Trop CXR. Looking for Rhythm abnormalities is also important. Fever can also cause Gabrahat.
• In Females in the Pregnancy Age group a HCG-UA is ordered
• If Patient has SOB I will R/O Thoracic Causes like Dissection/Pneumothorax and PE.
• If Patient has a presentation of Altered Mental Status I always order a CT Head.
• If Toxicology screen is available, I will order one.
• Co-Symptoms should guide further investigations.
• Discussing with the Relatives in key to educate them- that this is not Hysteria / Tension / Stress. Those are the diagnosis to be considered once Major Life threatening causes are ruled out.
• I have often Seen Marital Discord / Intimate Partner Abuse to be causes of GABRAHAT. So Going deeper into the history. Sitting with the patient with Privacy is the key.
• Anxiety / Panic attack also can be on the differential once Major causes are ruled out.
• Being a Compassionate Emergency Physician is the key. Communication is the answer and Competency to Care is crucial.
• GABRAHAT CAN KILL !

I want to Share a Web Review of what Non EM Experts say about GABRAHAT.

I feel a Well Trained Emergency Physician leaves no stone unturned to do the best for his/her patient

Web Review:

• http://bhj.org.in/journal/special_issue_tb/DPII_11.HTM
• http://hrelate.com/natural-remedies-for-anxiety/
• http://www.njhonline.com/1993/july_aug_93_vol_11_no_4/spider/ghabrahat.shtml

Author:

Dr. Sagar Galwankar

CEO of INDUSEM & Faculty of Emergency Medicine at University of Florida Jacksonville, Florida

@SagarGalwankar

Sagar completed his med school from the University of Pune (India). He attained Board Certified in Internal Medicine from the National Board of Examinations in India. Following this, he went on to train at the University of South Florida, USA in areas of International Health Diplomacy, Infectious Diseases and Emergency Medicine. He also holds a MPH from the University of South Florida and is a Board Certified Emergency Physician with the American Board of Emergency Medicine.

Sagar's academic and clinical career spans over a decade with experience in Education, Care and Research both in India and the USA. He has extensively published, cited and honoured for his works in International Medicine, Public Health, Infectious Diseases, Emergency Medicine and Injury Sciences. Sagar is the Founder and CEO of the INDO-US Academic Initiative for Emergency and Trauma and continue to play a defining role in establishing Emergency Medicine as a separate specialty in India.

He has had previous appointments at the University of South Florida and University of Florida in Departments of Emergency Medicine, Internal Medicine, Global Health and Mental Health. His areas of Interest include Emergency Medical Intelligence, Health Policy, Injury Medicine, International Health, Humanitarian Assistance, Quality Health Care Delivery in Emerging Economies and Global Health Diplomacy.  Sagar believes that "The role of the World's Largest and the Oldest Democracies namely India and United States is crucial for the future progress of transitional Economies and Peace across the Globe". Health is Definately an important part of this growth Story.

Originally published at beepers365.blogspot  on 11 December, 2016. Reposted with permission.

Human and Psychological Factors in Airway Management - Dr. George Kovacs

There is a lot more to airway apart from getting the tube in. This is one of the best Airway lectures that I have ever come across. A must listen.

My take-home points:

• Asking for help is not a sign of weakness.
• Goal is not just intubation but intubation without causing any damage.
• Traditional direct laryngoscopy is not going anywhere.

For more on Airway, Check out

Airway Pearls from the CRASH Airway Course - Part 1 and Part 2

This video is also available on youtube 

Cognitive pills for Cognitive ills: Errors in Emergency Medicine

Cognitive errors underlie most diagnostic errors that are made in the ED. And with time I have realised that our speciality is a vulnerable one, because we often commit some errors (delayed diagnosis, missed diagnosis, unnecessary imaging) which look like no-brainers to people upstairs in the ICUs and wards. Then why do we commit such errors?

May be because as everyone else, we often have a tendency to pursue more readily attainable goals.

There is a story about a jogger who came across a man on his knees under a streetlight one evening. He explained that he had dropped his wedding ring. The jogger offered to help him search, and he accepted. With no luck after a half hour, the jogger asked the man if he was sure he had dropped the ring at the place where they were searching. The man replied that he actually dropped it several yards away in the shadows. ‘‘Then why are we looking here?’’ asked the jogger. ‘‘Because the light is better,’’ came the reply. 

This is a topic in medicine which is rarely talked about, despite being a really important one for patient safety. These errors are universal but since we are often the first responders as Emergency Physicians, the brunt falls on us and we face the limelight. So, we need to find out a way to minimise these errors by developing a conceptual framework and strategies in this critical aspect of patient safety.

COGNITIVE ERRORS

Diagnostic errors arising through cognitive errors are those that are associated with failures in perception, failed heuristics, and biases are referred to as cognitive dispositions to respond (CDRs). There are a number of strategies for reducing them (‘‘cognitive debiasing’’)  like METACOGNITION, a reflective approach to problem solving that involves stepping back from the immediate problem to examine and reflect on the thinking process.

Some unique operating characteristics of ED predisposing to medical error:

• High Diagnostic Uncertainity
• High Decision Density
• High Cognitive Load
• High level of activity
• Inexperience
• Interruptions and Distractions
• Shift Work
• Shift Changes

There is huge list of errors which we can come across as clinicians and not surprisingly, all of them are evident in Emergency Medicine, a discipline that has been described as a ‘‘natural laboratory of error.’’ Lets familiarise ourselves with some of them:  

Various biases leading to errors:

1. Anchoring Bias: Anchoring bias causes physicians to stay with their initial impression of a case and fail to adjust to new information that would make the initial impression less likely. This often leads to prematurely ending their search or premature closure.
2. Gender Bias: the tendency to believe that gender is a determining factor in the probability of diagnosis of a particular disease when no such pathophysiological basis exists. Generally, it results in an overdiagnosis of the favored gender and underdiagnosis of the neglected gender.
3. Availability: Recent experience with a disease may inflate the likelihood of its being diagnosed. Conversely, if a disease has not been seen for a long time (is less available), it may be under diagnosed.
4. Premature closure: a powerful bias accounting for a high proportion of missed diagnoses. It is the tendency to apply premature closure to the decision- making process, accepting a diagnosis before it has been fully verified (When the diagnosis is made, the thinking stops)
5. Search satisfying: reflects the universal tendency to call off a search once something is found. Comorbidities, second foreign bodies, other fractures, and coingestants in poisoning may all be missed. 
6. Ascertainment bias: occurs when a physician’s thinking is shaped by prior expectation; stereotyping and gender bias are both good examples.
7. Fundamental attribution error: the tendency to be judgmental and blame patients for their illnesses rather than examine the circumstances that might have been responsible. In particular, psychiatric patients, minorities, and other marginalized groups. 

Few Cognitive de-biasing Strategies to Reduce Diagnostic Error Develop insight/ awareness: Provide detailed descriptions and thorough characterizations of known cognitive biases, together with multiple clinical examples illustrating their adverse effects on decision-making and diagnosis formulation. Consider alternatives: Establish forced consideration of alternative possibilities. Encourage routinely asking the question: What else might this be? eg: any pt who presents with flank pain/hematuria, force yourself to consider aortic dissection. Metacognition: Train for a reflective approach to problem solving: Metacognition is the process of actively stepping back from the pushes and pulls of the immediate situation (de-anchoring), reminding oneself of the limitations and failings of memory, seeing the clinical problem in a wider perspective than that dictated by the obvious presentation, perhaps reminding oneself of specific lapses or failures in the past, and finally activating known cardinal rules or caveats.   Decrease reliance on memory: Improve the accuracy of judgments through cognitive aids: mnemonics, clinical practice guidelines, algorithms, hand-held computers. Simulation: Develop mental rehearsal, ‘‘cognitive walkthrough’’ strategies for specific clinical scenarios to allow cognitive biases to be made and their consequences to be observed. Construct clinical training videos contrasting incorrect and correct approach. Make task easier: Provide more information about the specific problem to reduce task difficulty and ambiguity. Make available rapid access to concise, clear, well-organized information.Write the ddx in chart upon initial evaluation and re-visit the ddx when initial tests are back and when deciding disposition. Formalizing Handover: 'S BAR' Mneumonic for Handover - Situation, Background, Assessment, Recommendation Minimize time pressures : Provide adequate time for quality decision- making. Have the the attending doc and and the handover doc seeing patient/imaging together, its always better to review the H&P for handed over cases.  Feedback: Provide as rapid and reliable feedback as possible to decision makers so that errors are immediately appreciated, understood, and corrected, resulting in better calibration of decision makers. Understanding "how we think":  Type 1: The Intuitive/Reflexive Approach involves automatic decision making based on pattern recognition. It's fast, requires little effort and usually brings you the correct diagnosis, but it's very prone to error. Type 2: The Analytical/Problem-Solving Approach is more critical and logical. This is when you step back and think more carefully about the patient's presentation. It involves estimating pretest probabilities, continuous self-questioning, and considering alternative diagnoses. While it takes more effort, more time and is more resource intensive, it's reliability is much better than the intuitive approach, and is more likely to give you the correct diagnosis.  High Risk Situations where errors are likely: Night shifts, during handover, with patients at the extremes of age, the 'difficult patient' and the "difficult relatives"

Some Classic Errors:

1. Failure to consider a closed-head injury in an intoxicated patient
2. Incomplete consideration of AMI mimics before initiating thrombolysis 
3. Inadequate assessment of immunocompromise status in patients with animal bite wounds
4. Failure to fully assess the medical status of psychiatric patients before transferring to a psychiatric facility
5. Failure to consider tetanus immune status in patients with open wounds. 

Take Home:

1. Learn, practise and teach Metacognition.
2. Develop your own strategies to reduce errors (discussion, checklists, Incorporating simulation)
3. Use a Problem Solving approach instead of a Reflexive Approach.

For Further Reading:

1. http://www.cjem-online.ca/sites/cjem-online.ca/files/pg271(2).pdf
2. http://home.comcast.net/~jasoncillo/Cognitive.pdf
3. http://www.ncbi.nlm.nih.gov/pubmed/12915363