A rather painful ER shift. I had to call some surgical consultants, and they were less than thrilled, to put it mildly. My colleagues acted as though the fact that I am a surgeon ought to prevent me from calling other surgeons into the ER. On the other hand, when I tried to make a surgical assessment of a patient and act on it (giving pain meds to someone whose pain I thought was clear enough to warrant an immediate surgical consultation, but who then became pretty comfortable by the time they got to the ER), they weren’t happy with that either. So I’m just a little bitter with the guys who I thought were my friends for getting so uptight on me. I tried to play it as some ribbing back and forth, but they wanted to take it farther than that. This is the first time that I’ve really felt I’m not able to play the men’s game by their rules. I guess I just need to stop thinking about this in personal terms.
As for the clinical question, I’d welcome opinions on the subject of giving pain medications in the ER before the surgeon evaluates the patient. It serves me right, actually, because a few months back I gave another ER resident a hard time (jokingly, I thought) for doing the same thing, and he fiercely quoted me some literature articles (such as this one) decrying such an inhumane practice. I think perhaps one might avoid inflicting too much suffering on patients by distinguishing between community practice, where it might be an hour or two before a surgeon gets in to the ER, and academic practice, where the surgery residents make it a point of pride to evaluate any consult within ten or fifteen minutes.
Either way, I was insulted that the surgical team wouldn’t trust my evaluation of the patient. My physical exam skills haven’t been changed by the fact that I’m working in the ER this month. I’ve been laughed at enough times for taking abdominal pain seriously when it isn’t that I think by now I have a good idea of what constitutes “severe abdominal pain” for a surgeon. When surgeons say severe pain, or a rigid abdomen, they mean they want to go to the OR now. If that’s not your management plan, then the patient’s belly isn’t that bad. That’s why we don’t appreciate it when medicine consults us for “acute abdomens” in patients who are sitting up, talking, and drinking. The ER attendings, on the other hand, are frustrated at me for discounting abdominal pain of the gastroenteritis/pregnancy/peptic ulcer variety. So I know the difference between serious pain and non-surgical pain. (A surgeon at my medical school described it best. She said, “If the patient makes any movement quickly and easily when I ask them to, it’s not an acute abdomen. With real peritonitis, the patient won’t move unless they absolutely can’t help it.”)
December 11, 2007 at 10:33 pm
I believe that true peritonitis will not be masked by pain medication. It will dull the pain, but the patient will still have the findings. they may not be as dramatic, but they will be there.
December 13, 2007 at 1:12 am
i’m inclined to agree with kellie. experience would enable you to come up with the right evaluation even with meds on board.
the other thing i thought of had to do with the stabbing of the colleague in the back. where i trained, stabwound back was one of the first procedures learned. almost everyone did it. my back is, to this day covered with hard scar tissue, making it impervious to any more colligeal daggers.
how to deal with this? each to his own. i decided that i would take whatever was thrown at me and bounce back with a smile. i would never ever pass it down the line. i was never the stabber, only the stabbee.
surgeons tend to be ruthless in this was. loners etc. the question becomes, are you going to turn out that way?
December 19, 2007 at 3:32 am
Blimey – this was a lucky coincidence. I saw this entry when I was browsing through your blog last night, and then this morning, reading one of my review journals, I found this reference to a recent Cochrane review:
Manterola C, Astudillo P, Losala H et al. Analgesia in patients with acute abdominal pain. Cochrane Database of Systemic Reviews 2007, Issue 3, Art. No CD005660.
Of course, you may well have seen that already – if not, then I hope it’s of some help.