This is a first in a series of episodes about the cognitive process of differential diagnosis.
It’s called “The Thinking Series.”
Ginger Locke talks to the brightest clinicians in emergency medicine about how they think. They approach the concept one chief complaint at a time and dive into the complexities of clinical reasoning.
Dr. Brandon Bleess is a physician who is board certified in both Emergency Medicine and EMS. He’s the medical director for an aeromedical service in Illinois. He’s on the faculty at the University of Illinois’ College of Medicine and has been active in the prehospital setting since becoming an EMT in 2003.
Meet Dr. Bleess….
Connect with Dr. Brandon Bleess:
The NAEMSP Blog
Show notes:
The need to be masters at sorting through a complaint of chest pain.
It’s often our job to say what disease the patient is not having.
His list of life-threatening conditions that cause chest pain:
- MI
- Aortic Dissection
- Dysrhythmias
- Pulmonary embolism
- Pneumothorax / Tension Pneumothorax
- Pericardial Tamponade
- Esophageal Rupture (Boerhaave)
- Pancreatitis
- Pneumonia
- Cholecystitis
What to do with suspected ACS when there’s no STEMI on the EKG.
Advocating for the cardiac patient without a compelling EKG
How he thinks about PEs:
- Wells criteria
- PERC Score
- D-dimers
- S1Q3T3 EKG pattern
- Right Ventricular Strain EKG features
Ultrasounds of:
Nerd all the way out on right ventricular strain
His article about ultrasound on the NAEMSP blog
How do heart tones fit into the assessment?
The world’s best video on heart murmurs and extra sounds.
The importance of human touch during a physical exam.
Dr. Ed Racht‘s mental representation of thinking about chest pain.
Deep (heart-aorta) to superficial (soft tissue)
Anatomical structures versus body-systems approach
Remember referred pain from the abdomen.
Don’t forget neoplasms (tumors) and infectious disease!
What’s an Illness Script?
Cognitive pitfalls of Illness Scripts.
Keeping his mind open during the differential diagnosis process.
Cognitive biases we discuss:
- Premature Closure
- Anchoring Bias
- Psyche-Out Error – Anxiety is a diagnosis of exclusion.
Ginger’s 3 questions to ask during differential diagnosis:
- What’s the worst thing this could be?
- What findings do we have that conflict with the presumptive diagnosis?
- What else could this be?
Dr. Bleess reminds us to consider “What is the most likely?”
Avoiding Diagnostic Momentum.
STEMI equivalents: Wellens Syndrome and Sgarbossa Criteria
STEMI mimics
Thanks to Dr. Catherine Counts who connected us.
Dr. Bleess’ book recommendation: On Combat By Dave Grossman
Medic Mindset is on Reddit!
One suggestion when approaching the “chest pain” patient is to visualize the deepest structures and work your way out to the more superficial anatomy.
Special thanks to Strata5 whose infographic was the original inspiration for this episode.
Medic Mindset 
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