Abd pain

RedAirplane

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(Based on a scenario or two I have seen, scrubbed to prevent identification; I would like your thoughts).

It's a hot dry day without a cloud in the sky.

A family comes up to you asking for a bottle of water. You send your partner to grab some water and notice a male about 12 y/o who just doesn't look good. He is sweaty, flush red, in a slouching / tired posture, and has one hand on his abdomen. You offer him a seat and he takes it.

The parents advise you that their son was not feeling well so they wanted to get him some water. With their permission, you start asking a few questions. The pt is having a headache (3/10) and sharp abd pain (5/10) with nausea and dizziness. The headache is new and the abd pain, nausea, and dizziness have been worsening since morning. He had a hot dog to eat and hasn't drank much all day. The pt takes no medications and nothing like this has ever happened before.

Examination of the abdomen reveals a diffuse pain, unable to be located by the patient. Palpation does not affect the severity of the pain.

You suggest that the patient be evaluated by paramedics for possible transport, but they end up refusing care. You suggest that the pt be seen by his MD, but he does not have an MD. The parents say that they will take him to urgent care but don't want EMS/hospital because they don't have insurance.

How okay are you with this refusal? Your gut instinct wanted an ALS evaluation / transport unit to be called to the scene, but your partner and supervisor both seemed perfectly okay with this as an ordinary refusal.
 
OP
OP
RedAirplane

RedAirplane

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Minor with parents. Parents don't want a transport for a kid with a tummy ache.

End of scenario.

In the words of a famous talking lizard, "not my chair, not my problem."

#Bye Felicia.

Maybe EMT class scared me a bit much, but isn't sharp abd pain supposed to be worrisome?
 

ERDoc

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There is nothing specific about sharp pain. It could be intestinal cramping, appendicitis, gas, etc. Did you get a set of vitals? That may sway things.
 

Tigger

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In the words of a famous talking lizard, "not my chair, not my problem."
As we've discussed before, there may be no better reference.

Topically,
What do you think ALS will provide for this patient? Have you ever had a stomach ache that was pretty brutal? What did you do?

What are your differentials? It is important to at least consider what could be causing the symptoms as opposed to "something is abnormal, therefore I call for ALS."
 
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RedAirplane

RedAirplane

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In my limited experience, I was thinking appendicitis or some bleeding internal organ. But it seems I'm way off base.
 

Gurby

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Do you guys ever suggest to patients that they go to an urgent care over the ED? A lot of times, a patient will refuse transport after calling (or after their someone else calls for them) with something that seems non-acute. I often want to say, "if it was me, I'd go get checked out at an urgent care", but always feel guilty about it, like I should always advise them to just go straight to highest level of care to CYA.
 

chaz90

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Do you guys ever suggest to patients that they go to an urgent care over the ED? A lot of times, a patient will refuse transport after calling (or after their someone else calls for them) with something that seems non-acute. I often want to say, "if it was me, I'd go get checked out at an urgent care", but always feel guilty about it, like I should always advise them to just go straight to highest level of care to CYA.
I suggest this frequently and never feel any guilt about it. If requested, I'm happy to take a minor complaint to the ED or at least pawn it off to the BLS ambulance crew. If they're already refusing and ask for my advice though, I'm as honest as I can be with them.

I would only go to the ED for myself if it were something fairly serious, unable to be dealt with at a PCP or urgent care, or all other facilities were closed and my complaint/pain was time sensitive or unbearable. If they're presenting with something that doesn't strike me as any of these, I give them my honest advice that going to their own doctor or urgent care might be a better idea than driving to the ED.

We have a medical system that relies on more than just emergency treatment in hospital based EDs from emergency physicians. We in EMS aren't exposed to the alternatives quite as often, but we should be open to them when possible.
 

Brandon O

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In my limited experience, I was thinking appendicitis or some bleeding internal organ. But it seems I'm way off base.

Kids get abdominal pain with some frequency. You need to delve a bit deeper.

"Sharp" pain is more associated with peritoneal irritation than dull or vague pain, but in this case sounds diffuse rather than localized, so it may just be a youthful poverty of adjectives (or leading the witness). Is there constipation/diarrhea? Actual vomiting? Urinary complaints? Fever? Does the pain come and go in discrete phases (colicky pain), or is it steady or more vaguely fluctuating?

Is there any guarding? Rebound or other peritoneal signs (pain with walking, coughing, bouncing, heelstrike, etc)? Perhaps an obturator or psoas sign? Masses?

Most of all, does he look sick? Often that's the first question and you may not get too far past it.

Abdomens are hard, kids are hard.
 

DesertMedic66

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Do you guys ever suggest to patients that they go to an urgent care over the ED? A lot of times, a patient will refuse transport after calling (or after their someone else calls for them) with something that seems non-acute. I often want to say, "if it was me, I'd go get checked out at an urgent care", but always feel guilty about it, like I should always advise them to just go straight to highest level of care to CYA.
I would like to however our urgent cares will call us out for any ABD pains regardless of what they find.
 

EMSComeLately

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ALS diagnostics aren't absolutely definitive for ABD pain especially with a likely inconsistent history that comes with children especially. With pediatric compensation, even vitals aren't enough until later stages.

I like heat stroke or exhaustion for this; however, and would like temps, find out if the child was sweating before and has stopped or slowed (though presented as "sweaty"), check manual pulse for tachycardia, etc.
 

NomadicMedic

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Not to single the OP out, but event EMTs and new basics seem to cry wolf over calls that more experienced providers don't get particularly excited about.

At the end of the day, it's a kid with a belly ache. If he's not CTD and if mom and dad don't want him to go to the ED, you need to respect that. "Here's your water, find us if you need help."

Yes, it's a kid that doesn't feel well, but you don't know if he's tired because he was up playing video games all night, if he's been playing sick all day to get out of chores or he's wants to go home because he's missing his friends. It's the great unknown, and if the parents aren't particularly upset, you certainly shouldn't be.

I worked at a water park as an EMS provider for a couple of seasons and would hand out water, band aids and the like all day without feeling the need to get involved at any EMS level with the patient. They didn't come to get an assessment, exam or play 20 questions. They came and asked for a bottle of water or to cool off in my EMS station's AC. If the kid passes out or they show up at the first aid point "looking for help/EMS/to get checked out", the situation changes. Til then, "here's a bottle of water, need anything else? No? Have a nice day."

That may make me seem like a ****, but at some point you need to draw the line on how much you insert yourself into other people's problems.
 
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RedAirplane

RedAirplane

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Not to single the OP out, but event EMTs and new basics seem to cry wolf over calls that more experienced providers don't get particularly excited about.

At the end of the day, it's a kid with a belly ache. If he's not CTD and if mom and dad don't want him to go to the ED, you need to respect that. "Here's your water, find us if you need help."

Yes, it's a kid that doesn't feel well, but you don't know if he's tired because he was up playing video games all night, if he's been playing sick all day to get out of chores or he's wants to go home because he's missing his friends. It's the great unknown, and if the parents aren't particularly upset, you certainly shouldn't be.

I worked at a water park as an EMS provider for a couple of seasons and would hand out water, band aids and the like all day without feeling the need to get involved at any EMS level with the patient. They didn't come to get an assessment, exam or play 20 questions. They came and asked for a bottle of water or to cool off in my EMS station's AC. If the kid passes out or they show up at the first aid point "looking for help/EMS/to get checked out", the situation changes. Til then, "here's a bottle of water, need anything else? No? Have a nice day."

That may make me seem like a ****, but at some point you need to draw the line on how much you insert yourself into other people's problems.

I can respect that philosophy but it is hard for me to follow. Working in an office Monday-Friday and doing volunteer standby BLS on nights/weekends came out of a desire to help people, so perhaps I'm more overzealous than the full-time EMS provider. Especially because in my role we look for people who may be sick, dehydrated, lost, needing a bathroom, walking unsteady (EtOH?), rather than just standing and waiting for a call. The question "is this person a patient" is a tough one to answer, because EMT school starts with the assumption that the person in front of you is a patient.

I know that anyone can refuse care, and I wouldn't kidnap the kid. My basic question was... is this something that should have gone to the ED per medical advice, or is this in fact something minor? Consent or refusal needs to be informed, the information needs to come from the EMT, and I'm the EMT... so I wanted some guidance on this situation.
 
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RedAirplane

RedAirplane

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Kids get abdominal pain with some frequency. You need to delve a bit deeper.

"Sharp" pain is more associated with peritoneal irritation than dull or vague pain, but in this case sounds diffuse rather than localized, so it may just be a youthful poverty of adjectives (or leading the witness). Is there constipation/diarrhea? Actual vomiting? Urinary complaints? Fever? Does the pain come and go in discrete phases (colicky pain), or is it steady or more vaguely fluctuating?

Is there any guarding? Rebound or other peritoneal signs (pain with walking, coughing, bouncing, heelstrike, etc)? Perhaps an obturator or psoas sign? Masses?

Most of all, does he look sick? Often that's the first question and you may not get too far past it.

Abdomens are hard, kids are hard.

I thought he looked sick, moreso than the other hot, sweaty kids running around that day. You could see discomfort in his eyes, which is why I started asking questions in the first place.

Not that a sample size of one person is great, but the one time I had similar S/Sx, I went to the campus clinic, got punted to urgent care, and from there got punted to the emergency room, because that's the only place where they could do the diagnostics necessary.
 

Ewok Jerky

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If the parents seemed more concerned, or had shown up at the ED I would be more thorough ala Brandon O. But in this scenereo I agree with those that are comfortable letting him go. Maybe even "person not a patient", definitely RAs not AMA.
 

NomadicMedic

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Until they (or someone else) call for EMS, or you come across an unconscious person, they're not a patient.
 

RocketMedic

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I respectfully disagree- although it is not ny legal duty, I think that it is in both our own and the child's best interest and ethically the right thing to do to attempt to provide a comprehensive assessment and at least some measure of treatment for their son. There is a line between "sick" and ill, and this scenario as presented seems to have significant potential to be more serious than we anticipate at present.

Financially, there are concerns, but I think we can at least attempt to mitigate them. I like to impress upon the recalcirant just how little money and debt actually matter as compared to health.
 
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