EMERGENCY DEPARTMENT REAL LIFE
A Confusing Conversation With Another Doctor About Appendicitis
‘Please call my mom and tell her what I’ve got. She’s a doctor too.’
PLEASE 🙏 spend a minimum of 30 seconds reading this story. If you do not, I get PENALIZED in odious ways. I wish I was kidding about that, but I’m not. Thank you 😃
“Please call my mom and tell her what I’ve got. She’s a doctor too.” This request and information jot came from my 18-year-old ER patient.
He was a very nice kid. Well-spoken and polite, a local student in his first year of college. Bob Brown was his name.
After hearing his story, documenting his symptoms, examining him, and getting some basic lab results back I was virtually certain of his diagnosis.
A surgeon-requested CT scan of his abdomen confirmed what I already knew.
Acute appendicitis.
The appendix sits at the tail end of the colon about where the large intestine meets the small intestine. When this generally pinkie-sized, immune-tissue-containing, appendage gets infected and swells, it causes a characteristic set of signs and symptoms.
There’s pain, often diffuse at the start, then localized to the right lower abdomen as the process unfolds. An absence of appetite is also the norm. Some nausea and vomiting may occur. A loose stool or two perhaps. Pain increases with motion so patients often prefer to lie quietly, curled up in the fetal position on their right side. Fever and an elevated white blood cell count rounds out the picture.
There may be a few other details, but those are the important basics.
The physical examination is often classic as well. I’ll detail it momentarily.
If an abdominal CT scan is done for confirmation, which it commonly is, the appendix is swollen. There may be fluid around the appendix, a reaction to infection. Occasionally a calcified pebble of stool is seen within the appendix, a so-called “fecalith”, a “stone” (lith) made of feces that contains calcium.
Again, these are the basics.
Back to my patient.
After ensuring that Bob Brown was ready for the operating room, had an intravenous line in and flowing, was adequately treated for pain and other symptoms, was NPO (not allowed to eat, or “nil per os” in med-speak), and that a surgeon had been consulted, I returned to my patient’s bedside to explain.
“You have acute appendicitis. You need surgery.” I said. Then I added a few other basics, a very few other basics.
“I understand,” accepted my patient. “I’m OK to have the operation. But first, would you please call my mother and explain all this to her? She’s a Doctor too.”
“Sure,” I said. “What’s the best number to reach her?”
I called, and while waiting for the patient’s mother to answer I mentally summarized my patient’s story.
Doctor-to-Doctor conversations are frequently brief, focused because we speak a common precise specialized language, and packed with lingo. Medical discussions between professionals are all about transmitting relevant facts in a timely manner. Doctors are busy. Most are smart.
So, after my intro, “Hi Doctor Brown, I’m Michael Burg, an Emergency Physician caring for your son, Bob, at (hospital name)” and Doctor Brown’s intro in response “This is Doctor Brown”, I began.
“Your son Bob’s HPI includes 36 hours of abdominal pain, initially diffuse and peri-umbilical, now localized to the right lower quadrant. He’s anorectic and has had nausea and two episodes of non-bloody emesis and a single non-diarrheal stool. He’s febrile to 101.3, mildly tachycardic at 110 but improving with fluids. His exam shows rebound and involuntary guarding, most pronounced in the right lower quadrant. His Rovsing’s Sign is positive. The WBC count is 14 thousand with a left shift.”
I then described the CT findings of “appendicular edema with peri-appendiceal fluid.” ***
The entire blast took me about 3.7 seconds.
Dead silence from Doctor Brown greeted my clipped and professional presentation.
“Doctor Brown?” I asked “Are you there?”
“Yes” she replied. “What did you just say and what does it mean?”
As I noted earlier, Doctors are busy. Most are smart.
“Just curious, Doctor Brown. What kind of a Doctor are you?”
I expected perhaps “Psychiatrist” or “Ophthalmologist” with an addendum, “and I graduated med school when Rutherford B. Hayes was still in office.”
“I have a doctorate in English Literature.” came the reply.
“Ah, I understand,” I said. “Please let me start again.”
“Bob has appendicitis. He needs an operation.”
From that point on our communication improved, tremendously.
Communication is everything in these situations, so I’ll untwist the medical lingo liberally sprinkled above.
- *** Bob’s HPI — history of present illness, the story of the problem that brought him in today — includes, abdominal pain for a day and a half. The pain was throughout the belly at first, somewhat concentrated in the area around the belly button. Now the pain is centered in the right lower portion of the belly.
- He is not hungry (“anorectic”, an aside — truly remarkable in most 18-year-old males). He feels sick to his stomach currently and has thrown up twice. (The general term for bloody vomit is hematemesis. This is not present. If it were it might point to another ailment or an additional illness.) He passed one formed (non-diarrheal) stool since his illness began.
- He has a body temperature of 101.3 degrees Fahrenheit (38.5°C) (a fever in adults is generally defined as a body temperature greater than 100.4 (38°C). His heart rate is slightly fast, 110 (normal for adults is up to 100). He’s receiving intravenous fluids to treat this.
- When I apply pressure and release that pressure in the area overlying the space his appendix occupies, Bob experiences increased pain (rebound). His abdominal muscles are tensed (involuntary guarding) even before I press on his belly, a protective, involuntary, reaction to the infection inside his abdomen. This is most noticeable in the abdomen’s right lower segment, which is where the inflamed and infected appendix generally lies.
- Rovsing’s Sign (an outmoded examination technique which was still done at the time of this patient encounter) refers to pain that is felt in the right lower abdomen when pressure is applied to the patient’s left lower abdomen. The WBC (white blood cell) count is abnormally elevated indicating infection (most likely) and the body is producing a particular white blood cell type in abundance, the neutrophil, indicating (with some, but not perfect, degree of certainty) that a current infection is the cause. This neutrophil abundance is referred to as a “left shift” for historical reasons, not worth detailing here.
- The CT (Computed Tomographic) scan of the abdomen (wherein a computer is used to acquire and display images as through the patient’s abdomen is being seen in “slices”, like one would slice a salami, from the uppermost portion of the abdomen to the very bottom of the abdomen, the pelvic region) shows edema (swelling) of the appendix itself with fluid around it (peri-appendicular), indicating infection and or inflammation.
Phew! I’m pretty sure I couldn’t get through that — with pauses for questions and explanations — in 3.7 seconds. 😅
