It was a summer afternoon. Sunnybrook Hospital in Canada received an accident case. A young woman driver had a head-on collision with another car. She had suffered broken bones everywhere.
The doctors found multiple fractures in her ankles, feet, hips, and face. Initially, they missed the fracture in her ribs that they later found out.
During her diagnosis, the doctors found something else that was not right with the woman. Her heart was beating unusually. The rhythm of her heartbeat had become wildly irregular. It was either skipping beats or adding extra beats.
The emergency room staff soon diagnosed the heart problem – or thought they had. The woman told them that she had a history of an overactive thyroid. An overactive thyroid can cause an irregular heartbeat. So the staff no longer needed any further investigations for the source of the irregular heartbeat but to treat it.
By this time, they had invited an intern named Don Redelmeier, whose job at the hospital was, in part, to check the understanding of the specialists for mental errors. In other words, Redelmeier’s job was to serve a check on other people’s, especially doctors’, thinking.
As the emergency room staff was about to administer the drugs for hyperthyroidism to the woman patient, Redelmeier asked them to slow down. To wait. Just a moment. Just to check their thinking – and to make sure they were not trying to force the facts into an easy, coherent, but ultimately false story.
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