mobey Posted September 11, 2012 Posted September 11, 2012 Several times they called for permission, and every time, doc said no.. Likely b/c of the difficulty to diagnose, once it doesn't hurt anymore. I used to buy this excuse when a Doctors pain assessment was relevant to the patients surgical intervention. That ship sailed many years ago, there is no reason to have people writhing in pain so a doc can walk in and go "holy shit... his abdomen hurts, get him to CT".
Arctickat Posted September 11, 2012 Posted September 11, 2012 (edited) I used to buy this excuse when a Doctors pain assessment was relevant to the patients surgical intervention. That ship sailed many years ago, there is no reason to have people writhing in pain so a doc can walk in and go "holy shit... his abdomen hurts, get him to CT". "And give him some morphine." Sure glad we don't have to worry about orders for Morphine. Edited September 11, 2012 by Arctickat
Bieber Posted September 11, 2012 Author Posted September 11, 2012 That's atrocious, 1 C. Inhumane, senseless, and--in this case--would have contributed to a worsened condition. I feel bad for those patients who are needlessly made to suffer. Anyway... on to the exciting conclusion of this scenario! This was an actual patient I ran a few days ago. I was pretty certain right off the bat that the patient's hypotension and bradycardia were due to vagus nerve stimulation due to bearing down so hard due to the pain. Like you guys, I administered Fentanyl (75 mcg) and fluid (1 liter total) to the patient, and once her pain level came down (ending pain scale: 1-2/10) her heart rate jumped up to the 70's and her blood pressure increased. The patient was later diagnosed with an obstruction of the common bile duct, a complication which can occur following cholecystectomy. Here's a couple of articles on post-cholecystectomy illness: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015378/ http://emedicine.medscape.com/article/192761-overview http://www.ncbi.nlm.nih.gov/pubmed/7386502 Take away points from this scenario: -Consider vagal nerve stimulation in hypotensive patients (especially when they are also bradycardic) complaining of abdominal pain whose presentation does not suggest other causes for their hypotension (signs/symptoms of internal hemorrhage, risk factors for internal hemorrhage, etc). -Consider bile duct disease even in post-cholecystectomy patients, especially if the patient is complaining of RUQ abdominal pain but has no risk factors, history, or assessment findings consistent with liver disease or which can be attributed to another origin for the symptoms. Hope everyone enjoyed this scenario! Thanks for your participation!
Lone Star Posted September 11, 2012 Posted September 11, 2012 I came late to the party, and unfortunately was exposed to the diagnosis before I could step in with questions. The first thing I wanted to know was the type of delivery of the most recent child. With C-section, could it be possible that a sponge/clamp/other foreign object was left behind? I was also thinking possibly diverticulosis/diverticulitis in the ascending/transverse colon... I was considering 2-5mg MSO4 for pain management, but since there was no respiration rates given in the initial vitals, I would have inquired about that as well.....
HarryM Posted September 11, 2012 Posted September 11, 2012 Excellent scenario! I haven't come across this before and would have been lulled into a false sense of security that as her gallbladder had been removed there would be no further complications so long after surgery. Will keep it in mind if I ever come across a similar patient. Thanks!
Chief1C Posted September 12, 2012 Posted September 12, 2012 No shit.. I don't have access to my ePCR's from home, for obvious reasons. But I literally just within the last two weeks transported a patient for the exact same problem. Long hx of cancer of a specific type, the patient is still alive, and I wouldn't put it past them to sue. So I'd share my info privately, but not in the open boards. Anyhoo, transported initially for the pain; curled up in a fricken ball pain. Transported after discharge, with a diagnosis, in similar pain. Now I should say, that when we have someone that has a diagnosed specific condition, the medics follow their standing orders and address the pain. If it's not something that is affecting their vitals, or overall condition, these days, they tend to let it go. If it's my gutz, u better snow me or something. Then after the patient was discharged, the pain was difficult to manage, and we transported again for obvious results. Too much pain, and strong meds leads to..... Easy guess.
DFIB Posted September 12, 2012 Posted September 12, 2012 Great scenario Justin! I know this is a fish story but I was leaning toward a bile duct problem. You ran the scenario like the pro you are! Thanks Bro.
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