I called it

We had a crazy night the other night. We were busy and the computers were all down for scheduled maintenance for FIVE HOURS. FIVE. By the time the computers went down we had every room filled and four people in the waiting room. I went out to the triage room to triage the patients (we’ve largely switched to the system of triaging patients in the room and dumped the whole triage system)

While I was triaging we had an ambulance patient came in with high bloodsugar, so we pulled a bed from across the hall into our hallway for her. I had a couple patients I was concerned about in the waiting room. One had written “chest and neck pain” as her chief complaint and another wrote “severe abdominal pain” then there was another one that had “vaginal bleeding” as her complaint. Anyone involved in emergency rooms knows that chest pain is one of those *key things* that needs to be addressed immediately. It is totally and completely not kosher to leave a chest pain in the waiting room. They’re supposed to have an EKG within 5 minutes of sign in. Just incase they’re actually having an MI. “Vaginal Bleeing”‘s Hemaque checked in at the upper-end of normal so she was clearly not bleeding to death in the next few hours.

I decided however that I was going to triage all the patients before making any decisions, we had no rooms for any of them anyway, so what did it matter. The first person I triaged was chest pain, who looked positively pitiful. She came wearing a neck brace, a wrist brace, her eyes were all puffy and she was hobbling into the triage room. I learned during triage that she had a known compression fracture in her neck and also has chronic pain. I sent her back to the waiting room and was holding my breath because I’m sure my boss would have a heart attack. I called back “severe abdominal pain” who was on her knees in the waiting room leaning onto a chair with her husband rubbing her back. She was struggling to make it into the triage room, so we got her a wheelchair and wheeled her into the triage room.

You can just tell when someone is genuinely uncomfortable, you just can. This lady was in serious pain and 12 weeks pregnant. She was doubled over clutching her abdomen in the wheelchair and was a little sweaty. One of the first things on our triage sheet is vital signs, so I hooked up the machine and hit go. When her blood pressured popped up the on screen was when my heart started racing and I started asking the triage questions at rapid fire getting the most important ones out of the way first (due date, allergies, medications, known medical issues, have you had an ultrasound this pregnancy) There are a few things that raise blood pressure, stress, anxiety, pain. The general area of BP we see is 100-130 over 60-90…. if you’re a little over I don’t get concerned, you’re in an ER after all that gets everyones anxiety going and you’re probably in some pain if you’re in the ER anyway… when you’re BP gets to be 200s over 100s we get kinda freaked out, but by and large low blood pressure is way more frightening to us in the ER.

Her blood pressure (in obvious extreme pain) was 85 over 52. *gulp*

I took a time out during triage and pulled the charge nurse aside and said “umm, so do we have another bed for the hallway? Cause we need one” My patient was complaining of right sided lower abdominal pain and given her pain and BP I was concerned about #1: Ruptured ectopic #2: Acute appendicitis. (but there was no fever which I would expect with appendicitis) It could be either, but 12 weeks seemed a little far along for an ectopic (though not out of the realm of possibility, I was pretty sure it was appendicitis) 

She hadn’t yet seen a doctor for this pregnancy so we didn’t know if the baby was growing in the uterus or tube. I ended up wheeling her into the hallway and starting her IV in the wheelchair before the bed was available, with a low BP I was concerned we’d loose the opportunity for an IV if it went lower. I drew labs for everything they could possibly order including enough for a cross match just incase she was a ruptured ectopic and a stat OR case.

After some fluids and pain meds her BP was up to acceptable and she was able to carry on a conversation. Her ultrasound showed a normally growing baby right where it belongs. She was so relieved and I was convinced she had appendicitis. She had a history of ovarian cysts, which can rupture and cause pain too, but she was adamant to the OB doc that this felt nothing like when she had a cyst rupture. Minimally invasive (general surgery) came to evaluate her -and was a prick- did a total evaluation… and said since her pain went from 0-10 within a 2 hour period it was too fast to be appendicitis he said, she claimed right sided pain, but had rebound tenderness over her whole abdomen. and she had no fever and her white count was only 14. 

Now… I’ve only been a nurse for 5 minutes, but even I know that things aren’t always textbook and you have to take in the whole picture… 

The last appendicitis I admitted had a fever, backpain, and NOTHING else her white cell count was only 8… the doctor and I were totally betting kidney infection until the CT scan came back. Of course, 12 weeks pregnant it’s not kosher to CT so you have to make the diagnosis based on everything else. I personally felt she was just screaming appendicitis. The minimally invasive guy was convinced it was an ovarian cyst (I kind of feel that you need to listen to the patient at least a little, if she’s had an ovarian cyst before and volunteers the fact that this feels nothing like it, but apparently the medicine dude wasn’t listening) and the gyne people were convinced it was appendicitis, both wanted to avoid being too aggressive with someone 12 weeks pregnant, so I ended up admitting her with “abdominal pain”.

I called my mom on the way home since she was working in the OR the next two days and said “I admitted this girl with abdominal pain and I just KNOW it’s appendicitis, so pay attention if any appendectomies show up in the OR.

She called the next day and said “your girl is on the schedule for exploratory surgery” and I said “ooo, let me know if you hear what it is” Later that day I had the gyne resident look up the operation report and there was an ovarian cyst that the gyne people weren’t too impressed with, the appendix was surrounded by pus and looked inflamed so they called the minimally invasive attending (boss) to the surgery and his portion of the note says, and I quote, “Moderately inflamed purulent appendix removed, in the absence of any alternate cause of abdominal pain, she has been diagnosed as appendicitis.” mwahahahaha

It was also kind of sweet because a day or two later I was admitting another patient to a unit upstairs and as we were wheeling down the hallway I saw my appendicitis patient and her husband on their way out waving good-bye to the nurses. I said hello, she didn’t recognize me from the 6 hours we spent together in the ER, but it was nice to see her walking out of the hospital smiling all healthy 🙂 Made my day. 

Appendicitis I TOLD YOU SO! HA!

I was also completely relieved that day because we got a phone call from “chest pain”‘s actual doctors office wanting to know exactly how many of what painkillers she was prescribed because she’s a “known drug seeker” and they don’t want us giving her anything else. Whew, thank god because I felt SO guilty leaving a chest pain out in the waiting room for so long.

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