16 April 2010

Friday Flashback

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.

Originally posted 26 April 2007


  1. nothing substitutes for a gut feeling....pardon the pun!!!!! :)

  2. I want to see the ct scans! not sure about the whole decubitus thing though, maybe they were trying to move the bowel away from the appendix in some way. if I'm going to scan again I usually just go for the rectal contrast (techs and patients do hate it though). nice catch!



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