26 April 2007

Hubris, continued

Oh, what the hell. It's fresh in my mind after the last post and I can never resist telling one of my favorite stories. And you will see why I deserved my comeuppance.

A couple of years ago I came in to the evening shift and took sign out from my partner who was going off-shift. There was one case signed over which made my eyebrows go up a bit. I was a woman, early middle-aged, who had a story which weakly suggested appendicitis: right lower quadrant pain, no rebound, mild tenderness on exam. They got a CT scan on her and the radiologist did not think it was an appy, but was a little uncertain. So he consulted with one of his colleagues who had suggested (for reasons which to this day are beyond me) that the CT scan be repeated with the patient in the left lateral decubitus position (picture). I had never heard of such a thing, but I'm not a radiologist. Then the second CT scan was also indeterminate. So they decided to get another CT scan, in the right lateral decubitus position. The results of this CT were pending when I took over the case. My partner wryly informed me that his suspicion was kind of low anyway, so once the radiologists quit screwing around and decided this CT also was negative, the patient could go home with a diagnosis of "Abdominal pain, uncertain cause" and the standard precautions.

Sure enough, an hour or so later, I got the final results which were negative for evidence of acute appendicitis.

So I went in to tell her about the diagnosis and plan. She was a little anxious about the uncertainty, but I reassured her and went to re-examine her in a rather cursory, desultory fashion. Her abdomen was modestly obese and soft, and she did not even wince as I palpated deeply in the right lower quadrant. Idiots, I muttered to myself, all this fuss and not even pain on exam. I let go and stepped back, and as I let go, she gasped in sudden pain and sat up bolt upright. Okay, that was unexpected, I thought. Something just happened. I examined her again, a little more carefully, and again, though she really had no pain when I pushed on her belly, she had classic and severe rebound tenderness.

I hate it when this happens with a sign-out. Supposed to be a simple discharge, and now I have to look at the chart and re-think the whole thing. Hmm. She does have an elevated white count, and she has been in the ER eight hours getting her scans, so that's long enough for the rebound pain to have evolved -- you classically want a twelve-hour serial exam to rule out an appy, and eight is getting pretty near there. It was getting close to midnight, and I called the surgeon, who was a nice guy and a reasonable fellow, but unsurprisingly skeptical.

"So Brad, I have a lady here with an unusual presentation of appendicitis."
"Okay, what did her cat scan show?"
"Well, that's the funny part. She had three of them, one supine and bilateral decubitus CTs."
"Are you kidding me? That's insane. What did they show?"
"Well, they were all negative. But she's been here for 8 hours and clinically she has an appy on exam."
"Now I know you are kidding me. Three negative CT scans and you think she has an appy? You're on drugs. Send her home."
"Brad, I know it sounds bad, but really, you have got to see this lady."
"Fine, send her home and I'll see her first thing in the morning in my office."
"Brad, I can do that, but I don't recommend it. She'll have ruptured by then."
"You're killing me. Can you just admit her to me and I'll see her in a few hours on the floor?"
"I can do that if you prefer, but you'll just be taking out her appendix at four AM."
"Oh God. Fine. Send her up to the OR then." [click]

A couple of hours later I got a phone call from the surgeon.

"You know, I was really pissed at you for sending me that stupid case. And the thing that really pissed me off when I opened her abdomen and saw her black, necrotic appendix lying there, was the realization that the next time you call me with some stupid consult in the middle of the night, I am going to have to take you seriously and listen to what you have to say."

I should say that we have some really great surgeons and have a great relationship with them. I portray them as gruff but they are not in any way unpleasant or jerks, so don't read it that way.

I was very proud of my cojones that day, calling the diagnosis in contradiction of not one but three scans. I strutted around for quite a while after that. Which, as I said, is why I undoubtedly deserved my karmic comeuppance.


  1. 3 CT's? Daang! Nice work.

    I had a similar case last night. Did a 3P-2A swing shift when our secretary couldn't find anybody to cover the hole after one of the doc in our group had to under an emergent D&C for a spontaneous AB. Sad situation.

    Anyway, the case was similar to yours except only 2 CT. The sign out was, 20 y/o female, RLQ pain waiting for CT, normal labs, not pregnant, unremarkable pelvic, no CMT. In the first CT, the contrast hadn't opacified the cecum, but "appendix not visualized but no inflamatory changes seen in the RLQ." I go pound on her belly and repeated the pelvic exam. Pretty convincing guarding and rebound. Called the gen'l surgeon.

    "She's got all the classic signs."

    "No fever? Normal white count? for 4 days? Doesn't sound like an appy to me."

    "The exam is pretty classic though. She's got something if it's not the appendix. She's been here 5 hours and just spike a fever."

    "So what do you think it is?"

    Damn, don't ya hate it when a surgeon do that to ya?

    "Heck, I don't know. But it's something surgical, I know that much judging by her exam. If I had to make a bet, I'd say appy or Meckle's."

    "It could be just a colitis. How 'bout getting delayed images and let the contrast transit a li'l lower and call me in 2 hours."

    The second CT was still the same. I stuck to my guns. Surgeon came in, took patient to OR. Appy! Retrocecal. He knows me well from previous encounters over the year and have commented, "Whenever you call me, I know that it's the real deal."

  2. Wish you could have been my Dad's doc.

    He presented at 2 am with severe RLQ pain. After an x-ray (no CT) was sent home at 6 am saying it was nothing.

    At 7 am as my Dad is sitting in his easy chair trying to deal with the pain, the new Radiologist on duty calls him and tells him to get to the hospital ASAP. His film was mis-read and his appendix could rupture at any second.

    It ruptured 90 minutes later as he was being cut open.

    Fun times for Dad!

  3. So I guess that you won't find an appendix on CT if it's already ruptured no matter how many scans you do?

  4. I once sent a patient home after her RLQ pain resolved in the ED while awaiting labs. Exam was completely benign after pain went away. It was truly a rookie mistake made during my 1st month out of residency. Lesson learned. Pain goes away transiently at time when appy ruptures! Then peritonitis comes with a vengeance to make you look like an idiot.

  5. Three CT scans, on one patient, in eight hours?! Holy shit, I'd heard you Americans were trigger happy but f*ck me....

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  7. I was home in the States working in one of my formerly local A&Es and this poor girl came in, 11yrs. Barn door appendicitis. Generalised abdo pain, localised to umbilicus, moved to RIF; spiking fevers, rigors; vomiting, no movements for 24hrs; massively elevated white cells. Surgeons weren't "convinced." We got them a PFA. Still not convinced. AbdoUSS. Still not convinced. At this point she was in A&E about 4 hours, she had rebound and guarding, her fluid resus was done... They wanted a CT. I made a deal. CT for an admission to their list.

    The CT was apparently non-diagnostic and they weren't convinced. She perfed on the wards and was in hospital for a week.

    This is why I like working on Paeds in Ireland rather than the States now. We still call appendicitis as a clinical diagnosis rather than a radiological one and roughly 30% apps are normal at laparoscopy (and we take 'em out anyway).


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