Sometimes We Cannot See the Forest for the Trees

February 1, 2022   |   Healthcare Professional

What is the origin of this cute little idiom and what is its meaning? This catchy phrase originated as part of the works of John Heywood, an English writer known for his plays, poems, and collection of proverbs, circa 1546. It is an idiom used of someone who is too involved in the details of a problem to look at the situation as a whole. Is this true of us as medical providers? Most certainly. It is true of everyone who agonizes over detail and loses the ability to assess the larger picture. Today, as we face the unprecedented challenges of a global pandemic, our focus is on Covid. All our attention is on new literature for this disease. Of course, this laser attention is necessary, but there remains an array of other life-threatening options in this overwhelming diagnostic forest: heart failure and pulmonary disease, to name just two. Might we fail to perform the proper diagnostic tests, such as a BNP or CXR or CT scan with contrast to R/O a PE or a general cardiac test such as stress test and echocardiogram?

Where is your focus today? What are you personally on a hunt for that prevents you from seeing less subtle signs of another life-threatening disease? Depending on your specialty, you may be so focused on your own specialized organ system, that during your exam you fail to recognize the number five killer of patients, STROKE. It looks you in the eye and it can even wink at you but we can be oblivious to its sinister presence. 800,000 Americans have a stroke every year; people who could have been saved with recognition and immediate treatment. Immediate treatment means to prevent a clerk in our institutions from spending 20 minutes gathering insurance information and the patient waiting in a lobby when they should be in the main treatment area getting clot busters. If the clerk can only see the tree, then the caregiver will never see the patient in a timely manner. It is our responsibility to ensure that this does not happen to any patient.

Stroke is a disease that is no respecter of persons. It is not solely a disease of the elderly; on the contrary, it can affect young or old, male or female, people of any color, rich or poor. Some of our patients are greater candidates for this disease and must be cautioned and educated as to its possibility and its effects. Stroke should be part of the differential diagnosis in all questionable presentations. After the age of 55, our chances of stroke increase by double. Stroke can occur in children, teenagers, particularly in the scenario of drug use, in hypertension, pregnancy, diabetes, heart disease, cancer, using BCP, high cholesterol and, of course, smoking. According to the CDC, 1/3 of the patients diagnosed with stroke are under 55.

When you are younger and in relatively good health, you think that having a stroke is not a possibility, says David Liebeskind, M.D., director of Neurovascular Programs at Ronald Reagan UCLA Medical Center. “A stroke can happen at any age. Most younger patients, particularly those in their thirties, take a wait and see approach until it is too late” Just as there is a Golden Hour with a heart attack, there is a three-hour window in the treatment of stroke.

What are some of the warning signs? The first warning signs are sudden onset of dizziness or headache, sometimes accompanied by hiccups and nausea. I sat down and had lunch with a surgeon one afternoon and, while he was speaking to me, his words suddenly became garbled. I asked him to stick out his tongue: it was deviated to the left. We immediately left the restaurant and he went to a major hospital nearby, where he received his much-needed medication intervention. He was operating again within ten days with no deficits and, believe me, I was looking for them. A person can have changes in vision such as blurriness, diplopia or loss of vision altogether. They may have a sudden loss of strength or sensation or balance (it’s not their shoes). If you are anxious about your symptoms, or your patients, or someone you may be having dinner or a drink with, don’t be lulled to sleep. Call 911. Don’t let your friendly medical tech, ambulance tech or other HCP try to talk you or them out of it, go with your gut and don’t worry about embarrassment if you are wrong. A throw of the dice can be “snake eyes” and if you or they lose, it can lead to incapacitation or death.

What is the acronym for stroke diagnosis? FAST

F- Facial drooping

A- Arm or leg weakness

S- Speech problems

T- Time – 911: It’s time to do something.

Many of the potential problems are treatable: medication for hypertension, smoking cessation, correction of heart disease and medication treatment, treatment for carotid artery disease, reduction of heavy alcohol use, and blood sugar control in diabetics. An annual ophthalmological exam is prudent, as is an annual “good” physical exam by a provider who knows you and has examined your body personally in the past. This is not to be performed in an Urgent Care situation.

The treatment for stroke may be Alteplase or a newer drug, but the purpose of this IV infusion is to break-up the clot that has formed in your brain.

In conclusion, what has been going on in your personal life today that has the ability to interfere with your focus?  What disease entity are you engaged in that is taking most of your research time? Are you considering the whole patient in your exam or are you being so problem centered that you forget that there is a human being behind that laceration or fracture or abdominal pain or GYN visit? We “fail to diagnose” because we are generally too pre-occupied with looking at the chief complaint and not looking at more subtle presentations. A drooping eye or mouth is difficult to miss unless you are only looking at the ankle. But we are obligated to “do no harm” and to at least look at our patient. It is imperative that you have the best malpractice insurance for your specialty. It is imperative that you research that company and its strengths and weaknesses and to ascertain their financial status as a dedicated insurance company for a professional, just like you. Do you know their BEST Rating? This is as important as a brain scan. Do they have adequate financial support to pay out on litigations as this is why malpractice companies fail? Has this underwriter been doing business for a lengthy time or did they just arrive on the scene?  Make that decision today and secure that policy this week. You’ll be glad that you did.

By: Bob Blumm, PA-C Emeritus, DFAAPA
PA Advisor to CM&F

Photo by Cedric Fauntleroy from Pexels

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