There was this patient...
67 yo Hm transferred from outside facility where he presented at 8am c/o severe abdominal pain with N/V for one hour. PTA his niece called the advice nurse who recommended she call 911. In the ED at the outside facility his work-up was essentially negative, except he continued having severe abdominal pain. Transfer was arranged to our facility because their CT scanner was broken. At the time of transfer, although all tests were negative, he was becoming increasing hypotensive/tachycardic. In fact, per family, the other facility refused to give him more pain meds b/c "his BP was too low."
Upon arrival to our ER, patient was hypotensive/tachycardic and c/o continued pain. He was pale, and generally appeared unwell. He was immediately transferred to our close observation area. Initial bedside ultrasound was performed, and negative. Blood was drawn, IV hydration given, and plan of action discussed with an already very frustrated family.
Although on exam his abdomen was not acute, he c/o pain out of proportion to the exam. CT scan ordered. Bedside ultrasound x2, no free fluid, aorta with no aneurysm. Surgery was consulted.
The surgeons were in the OR, and said they would be available in 1 hour. IV hydration continued, pain meds administered, and eventually dopamine had to be started. NGT placed, antiemetics given, and lab results checked. No significant abnormalities.
After 2 hours of resuscitation patient was still pending surgery evaluation. CT also still pending. Clinically, the patient is doing worse. Remains hypotensive on dopamine, and tachycardia worsens. Surgery recontacted, and ?still in the OR, will be down in 10 minutes - recommended the CT. CT called, patient wasn't due until 1930. Radiologist called to help expedite the CT. Before CT could be obtained, patient decompensated with waxing/waning mental status. Femoral line placed, packed RBCs transfused. Repeat bedside ultrasound done. No obvious free fluid seen, aorta not visualized, but there was a question of free fluid near the bladder (i.e. bladder vs. free fluid). Up until this time, patient with severe abdominal pain, but no guarding/rebound. Now, patient with distended, tender, belly with rebound/guarding.
Surgeons arrive at the bedside as PRBCs are being transfused and ultrasound being done. They evaluate the patient, and still felt the need to do a DPL. DPL revealed frank stool. Immediately went to OR.
Patient doing okay, but still intubated in the ICU.
My frustrations are: 1) Why did the advice nurse not tell the patient to go to a hospital that could actually treat his problem? Had he a AAA, I doubt vascular surgery would be readily available, 911 isn't always the best option. Sometimes getting into your car and driving to a facility that you know can take care of you is a better option.
note-to-self: don't listen to the advice nurse. don't sit around all day at a hospital who can't do anything, pending a transfer. Have someone drive you to another hospital.
2) What took surgery so long to come see the patient. If they had a case, there should be another surgeon who can cover the ED. Otherwise, the ED is non-functional (by everyone's standard).
3) how can the other hospital *not* have a working scanner. They should not be accepting paramedic runs.
4) Why does transfer take so long. It's so simple to say, a simple concept...'we'll just transfer her..' but hours it takes. Dead time.
5) Why does it take so long to get an emergent CT, even after attempts are made to expedite the study? A more expeditious CT would have revealed this problem sooner than clinical decompensation.
6) Why did the surgeons do a DPL? Had it been negative were they *not* going to take him to the OR? It was an extra step, and a waste of time.
7) Why doesn't the facility have mechanisms in place to deal with true emergencies? The CT backed up, the surgeons in the OR. I called surgery upon pt arrival to our ED. 5 hours later he's in the OR.
I really do care. I did all I could do. I covered him with antibiotics. I called surgery 2 or 3 times. I called them very early. Immediately after my evaluation, ultrasound, and speaking with family. They knew he was sick...hypotensive/tachycardic with belly pain. They knew and asked about AAA. Did they think the patient would just go away? Why didn't the surgeon send his resident down...to evaluate if he didn't 'believe' us. It's not okay to just not believe, and not come see...
I know I did all I could. I could not cut his belly open. I could not physically carry the surgeon to the bedside.
I did all I could have done.