Monday, September 28, 2015

Sometimes a 9 is really a 9

As nurses we’ve been taught to take a patient’s word for his level of pain. Most of us don’t. Especially those high numbers. We tend to shade the numbers with what we think the patient may be experiencing based on physical assessment.  If the patient can respond calmly, that 8 or 9 can’t really be what they’re experiencing. With all the drug-seeking patients out there, I can understand that. However, I had an experience recently that will stick with me for a very long time. 

My son came to me at 10 pm on a Saturday night complaining of “gas”. I recommended simethicone and, when that didn’t help, an antacid. Not only did he continue to complain of “gas” but he started to vomit. OK. His diagnosis was wrong. When things calmed down a bit I asked a few more questions. Pressure in the upper abdomen, pain on the right side which didn’t radiate anywhere. At this point, I thought biliary colic (gallbladder disease). I recommended a trip to the ER since our favorite doc-in-the box location would be closed before we could get there. He declined stating that he didn’t want to risk high medical bills (he has a large deductible on his insurance). He said he would try to “sleep it off.”  It was 11:30 when he went back to his room. I waited 30 minutes to see if he would change his mind.

By midnight, he came back requesting a ride to the ER. Registration, triage (where he claimed a pain score of 7), saline lock insertion, blood for the lab, abdominal ultrasound. Then he was sent back to the waiting room because all the ED rooms were full. Apparently they have almost no exceptions to the “order of arrival” at this ER. Kids who can play video games while waiting are an exception – but I would wager that they go to the ‘fast-track’ side. Been there with kids myself, but if possible, I’m waiting until morning and going to Patient First. 

When my son asked if I had a knife so he could relieve his own pain, I thought he was kidding. When he started to moan every time he moved and to get progressively paler, I realized he wasn’t and got the attention of the next nurse to walk through the doors. She assured me he would be taken “in order”. 

It took about 3.5 hours from registration to placement in a room, not actually long for an ER Saturday night, but when someone who won't take Tylenol for a headache starts asking for pain medication I worry.

 Since the lab work and sonogram had already been done, we didn’t think it would take too much longer to get some pain relief. The nurse who admitted him asked his pain score – a 9 by this time.  His oxygen saturation was 93-94%. I was concerned that she would not take that 9 seriously, but her next question was, “is he always this pale?” She looked appropriately concerned when I assured her that he had been pink when we arrived. Clearly his pain was interfering with breathing because his saturation increased to 98-100% after a combination of Reglan, morphine, and Toradol was administered. 

The ER doc checked his sonogram report and informed him that he had several large gallstones, but his gallbladder didn’t “look too bad”. He offered to let him go home and follow up with a surgeon for elective cholecystectomy. After a brief discussion of possible complications of waiting and a few sarcastic remarks from me suggesting that he might not want to follow my example and wait until said complications occurred, my son said he’d rather “just get it over with” and the surgeon was summoned. 

He was assured the laparoscopic procedure was “very safe” and that everything would be OK. 2 hours later, the surgeon appeared with some very ugly pictures of my son’s gangrenous gallbladder. He told us that things had gone well, that he was able to complete the procedure laparoscopically but that my son would have to spend the night for observation and more IV antibiotics. Nobody could believe that he hadn’t had symptoms prior to 10 the previous night.  I wonder if they’d have taken his initial pain score more seriously if I’d told them that he once drove himself to the ER with a fractured elbow.

I decided to consult Dr. Google to learn more about gangrenous cholecystitis(GC). It's pretty grim as the mortality rate can be up to 20%. It's more common in older men (he's 34) who have cardiovascular disease or diabetes (he doesn't) and sometimes follows a delay in treatment -- not a 3.5 hour delay, but weeks or months of ignoring symptoms or taking a "wait and see" approach.

There are some specific findings which can indicate gangrenous cholecystitis See this NIH article for details , but ultrasound is not particularly sensitive and the presence of large gallstones is not particularly common. Interestingly, a high pain score does not necessarily accompany this condition either as the dying gallbladder loses its nerve endings. Basically, an elevated white cell count (above 17,000) is one of the few consistent markers and, while I haven't seen my son's labs, I expect that he skipped that one, too.

Open cholecystectomy used to be the standard of care for GC but a surgeon with plenty of experience in laparoscopic surgery is often able to produce better outcomes if he or she attempts the laparoscopic approach and decides whether or not an open approach will be needed.

There are a lot of interesting articles available, but most require institutional access or a subscription to the journal. From the abstracts I gather that elevated white cell count, age over 60, and co-morbidities of diabetes or coronary artery disease should have you thinking of urgent surgery. My son's experience is an example of why you can't trust statistics in making clinical decisions -- and it doesn't hurt to have a mom who doesn't trust you to come back later.