Abd pain

Yeah I'm done posting in this one. You keep on keeping on brother.
 
Ishan, don't let the ambulance driver drag you down. Risk mitigation on-site is a fairly important part of event medical, and no one wants to make the news for a public medical catastrophe.

As medical professionals, it is part of our responsibility to analyze people who present to and around us for help. A sick-looking kid certainly fits that description, and I would feel far better if I at least attempted to assess and discern potential causes of a problem rather than a simple dismissive Ambulance Driver handwave. Sure, it might be nothing, but it could be something too...and it doesn't hurt us to put forth the effort, it doesn't hurt the patient to be assessed and it doesn't hurt the parents to be approached about it.
 
Chewy20 said:
Wait...WHAT? hahaha



Even if they are on blood thinners they can be on their way.



You can not make them sit because they are SOB, nor can you force oxygen and ALS on people.

If you are not exaggerating about this place you work, it sounds down right ridiculous.
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This may surprise you, but some places are slightly more professional and expansive than "you call, we haul, that's all".
 
Ishan said:
(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.
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To me, this looks like dehydration, heat exhaustion, and a potential electrolyte deficiency at the very least.
 
Here is my concern with this scenario. This place is hiring people that are expected to be able to determine if someone is sick and make a recommendation about treatment/transport, yet they are hiring people that lack the education/experience to make such decisions. This is no offense to the OP, but this is a bad/dangerous set up for you as the provider and for the patients. It makes me wonder what kind of medical direction they are operating under.
 
ERDoc said:
Here is my concern with this scenario. This place is hiring people that are expected to be able to determine if someone is sick and make a recommendation about treatment/transport, yet they are hiring people that lack the education/experience to make such decisions. This is no offense to the OP, but this is a bad/dangerous set up for you as the provider and for the patients. It makes me wonder what kind of medical direction they are operating under.
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Similar to most 911 systems in this regard.
 
True, but at least in that situation the default is usually to transport when called.
 
ERDoc said:
True, but at least in that situation the default is usually to transport when called.
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Not always our most intelligent moments in the field, but it does cover a multitude of sins.
 
Gurby said:
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.
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We transport people to urgent cares as well as refer them to go POV to them or their PCP pretty often.
 
ERDoc said:
This place is hiring people that are expected to be able to determine if someone is sick and make a recommendation about treatment/transport, yet they are hiring people that lack the education/experience to make such decisions
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Have you ever met an EMT? We get 240 hours of education and then tossed onto the street.
 
I've met plenty of EMTs and was one for 10 years. I only got 110 hours of training.
 
LACoGurneyjockey said:
What would you do if you had a stomach ache that was sharp? Call an ambulance? Or stop eating ****ty hot dogs that are giving you gas and drink some water?
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I had a patient who was coming in with sharp epigastric pain after eating a gas station burrito. He had an aortic aneurysm. Of course being meth positive could have contributed.
 
JPINFV said:
I had a patient who was coming in with sharp epigastric pain after eating a gas station burrito. He had an aortic aneurysm. Of course being meth positive could have contributed.
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Still alive, I hope. That's like an EM final exam.
 
Brandon O said:
Still alive, I hope. That's like an EM final exam.
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Was that the ultimate Dx by the MD, or was there some clue in the field that told you that?
(The "pulsating mass" that the textbook talks about...)
 
Ishan said:
Was that the ultimate Dx by the MD, or was there some clue in the field that told you that?
(The "pulsating mass" that the textbook talks about...)
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The CT scan that the senior resident threw on because something didn't feel right. Also with that hospital's patient population, patients are assumed to be meth positive until proven otherwise.

We know he was meth positive because it became a, "Well, admit to surgery and pre-op labs." He was treated medically and ultimately discharged. Not all aneurysms need surgery.
 
Ishan said:
Maybe EMT class scared me a bit much, but isn't sharp abd pain supposed to be worrisome?
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nah, honestly how they describe pain half the time is completely inconsistent with what they have (not just kids)
Dont be worried just cause its sharp, and you do have to think not just from an EMT stand point, but like many others have said, from a regular every day stand point
He just has a upset stomache with no big fuss needed, and his parents may know if this happens every now and again to him or what have you
No reason to feel bad about asking questions, but you might be trying too hard to find an issue, you know what I mean? Odds are, hes hot maybe dehydrated, and its giving him a headache and a stomache ache, water and rest will work
and i like what was said about the urgent care, i would suggest it if it was appropriate
 
ERDoc said:
Here's a good article looking at the sensitivity/specificity/likelyhood ratios of classical signs and symptoms associated with appendicitis.

http://www.aafp.org/afp/1999/1101/p2027.html#afp19991101p2027-b7
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While I appreciate this sort of thing to help demystify bedside examination, I am always a little wary of trying to pin sensitivity/specificity figures on physical exam findings (or even components of the history). These are inevitably skill-dependent tools, just like interpreting an ultrasound or an ECG.

As Sapira put it, it's never particularly hard to find somebody who can't do something. (I had a roommate, for instance, who couldn't seem to wash dishes -- yet dishes are intrinsically washable.) This is probably increasingly true nowadays when few clinicians have serious training or experience relying upon their exam in isolation. You don't want to "validate" the sensitivity of Skodaic resonance in the Facebook generation; you want some old crusty fellow who drives a Cadillac and is still skeptical of CAT scans.

Of course, it's easy to take this to the other extreme and pull the old "I don't care what the RCTs say, I've seen this drug work!" Some areas just aren't very amenable to study.
 
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