HELLP, I Need Somebody: A Case of Implicit Bias Delaying Diagnosis of HELLP Syndrome

Abstract: Background

Cognitive biases and heuristics contribute to medical errors and worsened patient outcomes. (1) Here, we present a case in which the primary team erroneously diagnosed cannabis hyperemesis syndrome, despite concerning evidence for HELLP (hemolysis, elevated liver enzymes, and low platelets), a life-threatening syndrome in pregnancy that requires emergent delivery (2).

The consulting psychiatrist is uniquely positioned to recognize biases and overlooked diagnoses; however, it can be challenging to raise these concerns to a primary team with greater expertise. Here, we will present communication strategies from the patient safety literature that can be helpful in these difficult cases.Case Report

Ms. R was a 30-year-old Hispanic female, G4P0030 at 32+3 weeks complicated by intrauterine growth restriction with past history of cannabis use disorder and tobacco use disorder. She had been seen in the emergency department (ED) three times the past week for new-onset nausea, vomiting, and intense abdominal pain. The day of admission psychiatry was consulted for altered mental status because she had been yelling continuously; the primary team presumed that there must be a psychiatric component to her frequent presentations.

On initial interview, the patient was oriented without any disturbance in attention or cognitive processing. She communicated that she was in excruciating pain, periodically yelling into her pillow. She had no significant psychiatric history. The medical workup was concerning for thrombocytopenia, proteinuria, and rising transaminitis, raising our concern for HELLP. The primary team, indicated greater concern for cannabis hyperemesis syndrome, attributing her symptoms and abnormal labs to this syndrome. Later that day, the team obtained repeat HELLP labs; the labwork had worsened over the course of the day, prompting an emergent caesarian-section.

Discussion

Consulting psychiatrists are uniquely poised to identify cognitive errors made by primary teams. When biases are identified, particularly when patient care and safety are compromised, consulting psychiatrists have a duty to communicate these concerns to primary teams. The acronym CUS (state concern; state why you are uncomfortable; state that there is a safety issue) and the two-challenge rule provide useful frameworks for addressing potential safety issues with medical teams. (3-4) In this patient’s case, the CUS acronym was successfully utilized by our psychiatry consultation team to communicate concern for a missed underlying medical etiology. The consult psychiatry team can play an instrumental role in ensuring a safe medical outcome.