Geography Is Destiny A sprightly 68-year-old female presents at an ED, complaining of shoulder pain. When mowing her lawn today, the mower got stuck in an awkward spot and she had to twist and push...

Geography Is Destiny

A sprightly 68-year-old female presents at an ED, complaining of shoulder pain. When mowing her lawn today, the mower got stuck in an awkward spot and she had to twist and push hard to release it. She feels she may have strained her shoulder in the process (framing bias). At triage, she is noted to have shoulder sprain brought on by mowing (triage cueing). Her vital signs are all stable, and she is triaged to the Minors' (fast-track) area, where after a brief wait she is seen by an emergency physician. It was the practice in this department that emergency physicians would work the first 6 hours of their shift on the main floor and then go to the Minors' area for the last 2 hours. The implicit assumption made by those working in the Minors' area is that they will not be dealing with complex cases (ascertainment bias), also a manifestation of the Geography is Destiny bias. The EP takes a brief history and examines the patient. Her shoulder is slightly limited in range of motion but appears otherwise normal. He orders an x-ray, which shows no acute injury, but notes some osteoarthritic changes (confirmation bias). He orders a sling for the patient and advises her to take antiinflammatories and rest it for the next few days. His discharge diagnosis is ‘Osteoarthritis’. Several hours later, the patient returns to the same ED having experienced a ‘weak spell’ associated with some nausea and vomiting. She is pale, diaphoretic and hypotensive. An ECG at triage reveals an acute inferior myocardial infarct.