Bouncebacks
The Case of a 28-Year-Old
Pregnant Female with Shortness
of Breath
In Bouncebacks, which appears semimonthly in JUCM, we provide the documentation of an actual patient
encounter, discuss patient safety and risk management principles, and then reveal the patient’s “bounceback”
diagnosis. Cases are adapted from the book Bouncebacks! Emergency Department Cases: ED Returns (2006,
Anadem Publishing, www.anadem.com; also available at www.amazon.com and www.acep.org), which
includes 30 case presentations with risk management commentary by Gregory L. Henry, past president of The
American College of Emergency Physicians, and discussions by other nationally recognized experts.
Michael B. Weinstock, MD and Jill C. Miller, MD
Approaching Differences in Risk
Tolerance (Part 1 of 2)
What happens when the patient and
physician disagree on approach
to treatment, due to differences
in risk tolerance? Physicians
tend to be risk averse, due to
the quantity of patients they see.
For example, a 2% risk of
heart attack may be low
enough for a patient to decide
m .co
to forgo hospital admission,
es ag
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but be unacceptably high for
ler tab
nS t ar o
an urgent care physician who
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sees 100 patients with chest
pain per year. Patients may be
more comfortable with small risk
and ask their physician to tailor the
diagnostic approach to their schedule and
preference. The physician, after all, is in essence a contracted con-
sultant; an adult patient of sound mind and body is not
required to accept his or her recommendations. Some-
w w w. j u c m . c o m
times, we give advice but the “strength of
our recommendation” is not strong; “This
could be cellulitis and you should prob-
ably take an antibiotic.”
A reasonable patient may
choose to defer therapy and see
if their symptoms improve, and
we might choose to do the same
if we were in their shoes as a
physician-patient. Other times, our recommen-
dations are very strong but the
patient still chooses to defer
therapy despite potentially
catastrophic consequences.
The picture then becomes
murkier. The case presented here is an
example of one of those situations.
After the case presentation, we will
explore specific documentation issues and detail ele-
ments which need to be included on the chart when a
patient leaves against medical advice (AMA).
JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | Fe b r u a r y 2 0 0 9
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