A while back, I got called in to help a general surgeon on an emergent case. Typically, we don’t work with general surgery because they have residents. I work in plastics, OB-GYN, orthopedics, and a slew of other specialties but rarely general surgery. But, the residents have seminars and places to be, so once in a Christmas Star an emergent case rolls through the doors and we get asked to help out.
Like a good PA, I flipped through her chart before introducing myself. It just so happened that my patient was a young girl complaining of abdominal pain. She’d had the full work up, and the diagnosis was appendicitis.
As I’m speaking with her, I notice she is in excruciating pain. Not a little pain, but A LOT of pain. (Tiny red flag in my brain.)
The CRNA starts rolling the stretcher. As you go down the hallway, there are two spots that have little tiny speed bumps. It has to do with how the fire systems work or something. As we go over these tiny bumps, I peek back at the patient. She doesn’t flinch or moan as the stretcher jostles down the hall. Her pain is bad, but it’s constant.
Something felt off. (Any idea what it is yet?) I’m no general surgeon, but the picture didn’t add up.
I didn’t think much of it because I figured everyone involved knew more about it than I did. (And they do).
We got the patient onto the operating table and still no wincing or scrunched up face. Just that same constant serious abdominal pain. I had an odd feeling as we went to scrub.
Back inside, we draped the patient, made our incisions, and put in our trocars. We slid in the scope, and that tickle in the back of my brain was satisfied. We were not dealing with appendicitis.
Any guesses?
There was about 6 cm of black small intestine. It wasn’t subtle. Like black black. We immediately opened her belly and started looking along her small intestine. In less than a minute we found the problem. There was a thin adhesion (think string of scar tissue) that was strangling the bowel adhesion. We snipped the adhesion with a pair of scissors and closed her up. The whole case took about 15 minutes. Her bowel was beginning to pink back up, and we hoped for the best.
The good news for her was that we caught it very early. But, that’s not the part of the tale I want to focus on .
Here’s the part of the story that stuck with me:
Pain out of proportion to exam = ischemic bowel.
A kid who has abdominal pain on exam that is excruciating when the car hits bumps on the way to the hospital is appendicitis.
(Peritonitis hurts when the peritoneum is moved. That’s the layer that covers the inside of the abdomen and the appendix is usually wrapped in it. Pain with palpation over McBurney’s point is due to pressing on the peritoneum near the appendix.).
Kid who has pain with motion of the abdomen = appendicitis.
Key terms. Real life.
Key terms don’t come out of thin air. They’re key terms for a reason. They will show up on your exam and they will show up in your practice.
Ignore them and you’re definitely risking your scores and possibly your patient’s health.
You can learn them here:
Brian Wallace