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Anecdote-based Emergency Medicine #2: Abdominal pain

Author: Chris Odedun / Editor: Nikki Abela / Codes: CAP1, CC1, CC2, CC5, CC7, HAP1 / Published: 17/07/2018

Stories can help us understand patients, ourselves and colleagues better, and so be better emergency physicians. What are your learning points from the narrative below? We will zone in on some of ours at the end, but please share yours with us in the comments section or on Twitter.

Enter FY2.

“Chris, can I handover a patient with you?”

No, skedaddle away. I’m trying to concentrate on signing this ECG.

“Yes of course. Tell me.”

“There’s this man. 44 years old with abdominal pain. It started all of a sudden this evening, in his epigastrium. He’d eaten chicken & chips in the afternoon. Then. Vomited. He had some. Morphine with the. Ambulance service. He’s still. Moaning and complaining of pain. He was rolling around on the floor when I was trying to get a. History, I couldn’t examine him really. I think. He’s got gastritis.” (The FY2’s sentence structure was perfect, my mental interruptions added all the extra fullstops.)

That’s what I “heard” anyway. A fractured, intermittent encryption of a patient problem. Description is what I meant to write but autocorrect describes the coding errors much more accurately.

“Ok. VBG: normal pH, normal electrolytes, normal base excess. Glucose 23 – diabetic. lactate 3.4. Neither here nor there. Probably another exaggerator. I’ll go review him soon, can you prescribe some more analgesia before you leave please? I assume we are still waiting for his bloods.” I replied.

Meanwhile

  • Full Handover
  • Discharge
  • Take on an ambulance handover.
  • Go to resus
  • “Can you come listen to this kid’s chest?”
  • Drink water
  • Referral
  • Escalation

1 hour later I go review the man. Discharge him home I hope. The nurse who triaged him is there.

“I saw him an hour ago, Chris. His pain wasn’t so bad then. He’s had a couple of litres of fluids. Some anti-emetics, buscopan, mucogel“.

He’s moaning in pain. I ask him to stand up, he does so with extreme difficulty. He looks pale. He isn’t really distractible from this pain. It comes in waves.

Abdomen. Really tense. Maaaaaaybe not quite so exaggerated.

Ok. Repeat gas. Base excess -10. Lactate 3.6 – oh, a real lactate.

This guy needs to see a surgeon. He also needs some morphine, and lots of it.

CT scan: Lots of free fluid – lots. Central twisting of bowels loops and vessels – internal herniation, ischaemic bowel.

More morphine.

I feel bad now. Bad for my dismissal of the problem. Bad for the delay. Bad for real surgical pathology.

Surgeons come – and go. Needs to go to theatre.

I handover, and reflect.

Editorial comments:

There are two stark learning points from Chris’ story here for me:

1. Handover

2. Abdominal pain/Volvulus

Handover is one of the most dangerous things we do in medicine. Don’t believe it? Well, that’s what the BMA and the National Patient Safety Agency (NPSA) say, and there’s lots we can do to make sure our handovers are more effective, and most importantly, safe. The infographic below outlines the BMA and NPSA’s advice – try and think how they could be applied/optimised for the patient and teams in this story.

PaediatricFoam also have a really good blog post about human factors which affect handover which we suggest you read.

If you “zone in” on the story, you will notice that the patient was handed-over in an informal setting, while the clinician was distracted, and probably did not pick up a number of cues that the patient was unwell and needed early review. This happens when we are task overloaded and trying to juggle multiple things at once. It also happens when we are interrupted – a common occurrence for any senior in the ED. There’s lots more you can pick up from this story, human factors wise, but that definitely resonated with me.

Abdominal pain/Volvulus: Patients presenting with abdominal pain can sometimes be tricky for juniors reviewing them, especially if they do not have much general surgical experience. This patient was neither young, nor old, and initial gas was borderline (although many would argue that initial lactate was abnormal, it could have been raised due to vomiting). He wasn’t old, so didn’t need a senior review. Epigastric pain after eating chicken and chips sounds like gallstone pain doesn’t it? But in a patient rolling around with pain, labeling them as an exaggerator is a “diagnosis of exclusion” so to speak. In some places where I’ve worked a lactate >3 with abdominal pain would get you a CT abdomen with surgical review within the hour. It’s easier for more experienced clinicians to recognise the unwell patient, but we can only say this with the power of retrospect – in a busy department, without strict policies in place, this is not always possible and we are much wiser when we reflect. You’ll all have seen the RCEM safety briefing on abdominal pain, released a few years ago. The BMJ have an excellent review article on caecal volvulus and the way it may present here, if you fancy a bit of revision.

There are many other take-homes from this story and we would love to hear yours in the comments section below or on twitter.
Further reading

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1 Comments

  1. Osita Ogbonna says:

    I find handovers also a delicate time in patient care so I think is best to actually review case notes fully of any patient handed over so anything missed can be picked up.

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