Whatever you are, be a good one

“I know it’s your first heartbreak. I know it hurts. Nothing hurts like the first one.”

Things I look out for:

1. vasculopaths - has this patient had a stroke, an MI, DVT? Do they smoke? Are they diabetic or had gestational diabetes? Do they have HIV, rheumatoid disease? A combination of these? Is this a preemie baby? I always get extra suspicious for these folks. 

2. Is the pain out of proportion to the physical exam? You’ll know if you bump the stretcher and the patient grimaces like you punched them in the gut. Another way to check for shake tenderness is to ask the patient to puff their belly out to touch your hand a few inches above their abdomen, or ask how the ride over was. If everything hurts, be alert for a surgical abdomen. 

3. Are their vitals telling you something? Hypotension +/- tachycardia +/- fever = sepsis. Start hydrating right away. Don’t be fooled by numbers that are altered by meds like betablockers, ibuprofen, acetaminophen. 

4. Because I’m in a teeny hospital, if my physical exam looks sketchy, and my index of suspicion is high, I’m getting stat labs, checking the weather, and getting ready to transport my patient. Do an abdo 3 views to look for free air or megacolon. Look for elevated WBC, lactate, CRP. Do a urinalysis too. 

This hurts. It’s a horrible way to die. It gets missed, especially in women. It’s one of the diseases that early detection really can save a life because the surgeon can get rid of the jerky piece of bowel before things get out of control. Be aware that it exists and keep it on your differential. I usually find out with the plain films the patient is FOS and has a low pain tolerance, but then I get to stop everything there and give large amounts of lactulose. Easy peasy.