Student Case #RR02

[rev ronin]

I'm going to ask that prior EMTs and paramedics sit this one out--this is for pre-PAs and PA students without prior emergency medicine experience.

 

You're waiting to use the unisex bathroom in the staff lounge of your well-established yet rural Central American clinic. You are doing a week long surgical clinic for the local population, mostly hernias and hysterectomies, and your team has been in-country for four days. A young woman from your team exits the restroom, semi-stumbles 10' to the couch, and slumps down into a fetal position and starts crying.  She complains of sudden onset abdominal pain that she thought was gas, but when she went to defecate, the pain got worse and she almost passed out.  You are the only person in the room with your patient.

 

What are your initial actions?

 

What are you initial questions?

 

What do you want (but probably don't have)?

 

What do you want to have happen next?

[rev ronin]

I would have expected some response before this.  Unfortunately, I will be traveling tomorrow and less able to provide feedback on responses.  I emailed EMEDPA the case, so he may chime in and help out if he has time and sees some contributions here worth commenting upon.

[LT_Oneal_PAC]

I'll take a stab. On my phone so my responses will be brief because I hate typing in this.

 

Supine position. Perform abdominal exam. Don't make me list it all out for the special tests. Auscultation first of course.

Age, race, PSH, PMH, GPAL

When, where, and characteristics of pain. Bunch of questions about stool characterics and bowel movements habits, menses, and intercourse/contraception. Consumption of local food?

 

I'd want Hcg/CBC/CMP/ESR/CRP, transvaginal US, possibly abd XR, CT with/without contrast depending on previous. I mean, I could list things all day long that this could be and confirmatory tests without more info.

 

Get surgical consult. I'm assuming plenty of surgeons around.

 

 

[EMSGuy1982]

Bummer no EMS people can answer. I have a pretty good idea. :-)

[rev ronin]

Bummer no EMS people can answer. I have a pretty good idea. :-)

Exactly! :-)

[rev ronin]

I'll take a stab. On my phone so my responses will be brief because I hate typing in this.

 

Supine position. Perform abdominal exam. Don't make me list it all out for the special tests. Auscultation first of course.

Age, race, PSH, PMH, GPAL

When, where, and characteristics of pain. Bunch of questions about stool characterics and bowel movements habits, menses, and intercourse/contraception. Consumption of local food?

 

I'd want Hcg/CBC/CMP/ESR/CRP, transvaginal US, possibly abd XR, CT with/without contrast depending on previous. I mean, I could list things all day long that this could be and confirmatory tests without more info.

 

Get surgical consult. I'm assuming plenty of surgeons around.

 

122/66, HR 60 RR 40, temp not taken.  Very diaphoretic, even for the climate, skin cool & wet.

 

Abdominal exam is not well tolerated, tenderness is a bit worse on R side, but lower than McBurney's.  Pain is described as severe, that got really intense with straining to defecate and has not improved since, retropubic to umbilical, radiating to buttocks.  Auscultation of normal bowel tones.

 

28 YOF hispanic, negative med/surg history, G1P0 with a known home HGC+ prior to the trip. LMP 5 weeks ago.  Has been eating the same food as rest of team, prepared by clinic-employed locals who have been trained to U.S. food worker sanitation standards.

 

Stool characteristics unremarkable per history, recent stool has successfully flushed.  Patient denies vaginal or rectal bleeding, and TP (which is thrown into adjacent wastebasket, not flushed) shows no obvious signs of blood.

 

HCG is qualitative only, not repeated. CBC, CMP, ESR, CRP unavailable.  Hematocrit is 35.   Abd U/S equivocal, transvaginal U/S unavailable, X-Ray unavailable.

 

That was a very good first list, but you missed pretty much exactly one thing: Soc.  Patient has been married for 5 years, and is an incredibly fit marathon runner.  This may (should) change your perception of her HR.

 

DDx?

[LT_Oneal_PAC]

Rebound tenderness? Don't think so, but just checking. Straight leg raise? You didn't mention if CT was available. Just kidding ;)

 

In order of suspicion

 

Ectopic

Ovarian torsion

Appendicitis

Obstruction

Perforation

Ischemic bowel

[rev ronin]

It was indeed a ruptured tubal ectopic.  The surgical DDx was pretty much that vs. torsion, but given LMP 5 weeks ago... Exploratory laparotomy was done (we have six surgeons and 3 ORs), ~2l blood evacuated, bleeding controlled, tube repaired.  Laparoscopy was considered, but the available tools were just not robust enough for the surgeons to consider it, and we had been doing all open procedures all week. Type comptaible blood was available, but not used because of the lack of full cross-match capabilities.  Postop crit was 19.  HR never went above 100.
 

Patient was Medevac'ed to the states, but that took almost 24 hours to happen.  She's now pod2, and recovering nicely.

 

Appendicitis is rarely sudden onset.  SLR was not done, nor did I do any of the other appendicitis tests--Jar, etc. Obstruction and perforation didn't fit the history, and ischemic seemed remotely possible, but belly was full of blood on opening, so that settled it.

[Guest JMPA]

Rebound tenderness? Don't think so, but just checking. Straight leg raise? You didn't mention if CT was available. Just kidding ;) In order of suspicion Ectopic Ovarian torsion Appendicitis Obstruction Perforation Ischemic bowel

look for the flags in the history. remember 85% of diagnosis is from hx, "G1P0 with a known home HGC+ prior to the trip. LMP 5 weeks ago" and pain with valsalva

[LT_Oneal_PAC]

It was indeed a ruptured tubal ectopic. The surgical DDx was pretty much that vs. torsion, but given LMP 5 weeks ago... Exploratory laparotomy was done (we have six surgeons and 3 ORs), ~2l blood evacuated, bleeding controlled, tube repaired. Laparoscopy was considered, but the available tools were just not robust enough for the surgeons to consider it, and we had been doing all open procedures all week. Type comptaible blood was available, but not used because of the lack of full cross-match capabilities. Postop crit was 19. HR never went above 100.

 

Patient was Medevac'ed to the states, but that took almost 24 hours to happen. She's now pod2, and recovering nicely.

 

Appendicitis is rarely sudden onset. SLR was not done, nor did I do any of the other appendicitis tests--Jar, etc. Obstruction and perforation didn't fit the history, and ischemic seemed remotely possible, but belly was full of blood on opening, so that settled it.

Ectopic is what I thought, but couldn't rule out torsion. The rest of the DDX was really just fluff and zebras. 2 Dx doesn't qualify as much of a differential.

[LT_Oneal_PAC]

look for the flags in the history. remember 85% of diagnosis is from hx, "G1P0 with a known home HGC+ prior to the trip. LMP 5 weeks ago" and pain with valsalva

Yeah, it was kind of obvious. I saw it.

[ktcan10]

WOO HOO! I was right! Ectopic! That's my favorite scenario to throw at my EMT students...I've been biting my tongue over here. :) i didn't know all the tests to ask for or what the blood results meant, but I had my EMS suspicions. 

 

Awesome case, thank you! You should post more of these...I, for one, would love it. 

[rev ronin]

Awesome case, thank you! You should post more of these...I, for one, would love it. 

I will... when they actually happen to me.  This is the first one I actually saw develop (literally) right in front of me, and it was pretty scary.

 

The reason I did not want EMTs or Paramedics participating is that the simple, narrow DDx we teach 'em ("Any woman of childbearing age with sudden onset abdominal pain has a ruptured ectopic pregnancy until proven otherwise") would have entirely short-cut the process and jumped straight to the right answer. :-)

[ktcan10]

I will... when they actually happen to me.  This is the first one I actually saw develop (literally) right in front of me, and it was pretty scary.

 

The reason I did not want EMTs or Paramedics participating is that the simple, narrow DDx we teach 'em ("Any woman of childbearing age with sudden onset abdominal pain has a ruptured ectopic pregnancy until proven otherwise") would have entirely short-cut the process and jumped straight to the right answer. :-)

 

Sounds pretty scary. I've never actually seen one in the field, but you're absolutely right...the obvious conclusion from an EMS perspective was ectopic pregnancy. 

[PM2PA]

Young female with abdominal pain. Ectopic first suspicion 100% until proven otherwise.