Half of the general surgery attendings at my hospital will do appendectomies laparoscopically. The other half routinely do them open, arguing that it’s faster and requires less equipment (and is thus less frustrating than trying to get techs trained mainly on ortho equipment to get right in the middle of the night), and that a 2cm open scar is no more painful or unsightly than three 0.5-1cm port sites.
My problem is that, after two and a half years, I still can’t remember which half is which. Thus, when I’m explaining to patients – you have appendicitis, you should have surgery tonight, I’ll call my boss and set it up – I usually give them the wrong spiel. Whether that laparoscopy is quick and easy, or that an open incision is quick and easy – I always get it mismatched. Overall I’m getting better at telling patients ahead of time what the attending’s plan is going to be, which only makes it more painful to have to go back and correct. . . (You may wonder why I’m trying to predict the plan. It looks extremely unintelligent and unprofessional to take the history and physical, and then walk out of the room without explaining anything. If you can’t give the patient some kind of diagnosis, and an idea of whether they’ll be admitted, and whether or how soon they’ll need surgery, it looks as though you’re completely clueless, and not a doctor at all. Much more satisfying all around to immediately say, this is what’s most likely wrong, you’re undoubtedly being admitted, and I expect surgery tomorrow morning; let me check with the boss, and I’ll let you know the final plan. Of course, only satisfying if you get the diagnosis and plan right the first time.)
Tonight it was fun, though. One of the ER residents, feeling cocky, decided to try selling us a case of appendicitis based only on history and physical (how old-fashioned). I had to admire his idea (unlike some of his colleagues’ other attempts, he picked a patient with an appropriate history and physical, rather than say a 24-yr old woman with atypical symptoms). So I bought it, and then I managed to sell my attending on coming in to operate in the middle of the night without a CT scan. . . and we were both right, which was good for us and for the patient.
(And you thought the title referred to the Democrats’ scheme of taking the “public option” off the table to quiet public outrage, then slipping it back in and squeaking it through without adequate debate. . . don’t get me started. Here’s to obstruction and deadlock in the Senate.)
Cut On The Dotted Line 
November 19, 2009 at 8:25 pm
this is interesting because i just sat an exam (sorta similar to step 2 CK) asking us what investigation would i choose for the following scenario:
25 yo male with no prev med hx p/w 1 day history of peri-umbilical pain that migrated to the RIF today. Some nausea and vomitting. O/E: tenderness in RIF. White cell count elevated.
I.e. classic appendicitis.
there are options like abdo ct, abdo ultrasound, and an option of : “no further ix needed”. which is what i chose.
i would understand the difficulty in diagnosing appendicitis in children, and agree that studies have shown abdo CT is warranted in uncertain cases. but in classic cases, do you think any further investigations is warranted at all?
November 20, 2009 at 8:00 am
Jeffrey – Most of the attendings at the adult hospital will insist on a CT, which is what made it so much fun to sell this one without. I enjoyed working at the children’s hospital, where they would go to any lengths to avoid doing a CT, and thus we constantly got to make the decision to operate based on clinical judgement.
I do think that if you have a good history, and the physical exam is significant enough, it’s reasonable to proceed to the OR without further testing. Also, if you were going to do it laparoscopically, that might decrease the incentive to scan women (the population that is especially puzzling), since you know you’ll have the chance to look for ovarian cysts etc.
In the pediatric population, they would sometimes do a CT looking for an abscess, which they would then drain, and do an appendectomy a few weeks later. In adults, even a major perforation/abscess would still be treated (in the US) with immediate surgery, so that wouldn’t be a consideration.
November 21, 2009 at 8:58 am
[…] In question 2, classic appendicitis. We recently had such a question, and one of the options was “no further investigation required”. Other options relevant include abdo U/S and abdo CT. I chose the first one. When the diagnosis is clear, there is no need to waste unnecessary resources. I raised this point with Dr Alice, a surgical resident in USA, who blogs at “Cut on the dotted line”. I did learn something from her comment. […]
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