CHAPTER 8 – A 15 YEAR OLD GIRL WITH RLQ ABDOMINAL PAIN:
IT IS AN APPY… RIGHT?
- A 15 year old girl with RLQ pain
The other day I worked with someone who ordered a CBC for the evaluation of RLQ abdominal pain. “Why,” I asked. “The surgeon wants it.” Well, my thought is that if the surgeon is called, on that few percent of abdominal pain patients who actually have a surgical problem, we can order it after the CT results shows the appy.
This does sound a bit ‘high and mighty’; it is very standard practice to order a terrible test, such as a WBC count, when you are getting a very great test, such as a CT scan. Then here is the lession, if the CT is negative, and the WBC count is elevated, document in a progress note why you don’t think something bad is happening.
This elevated WBC count hurt the doctor in court and hurt the patient at the second visit (when it was low) causing the surgeons to suspect viral gastroenteritis (who is still diagnosing a viral syndrome with a low WBC count? – surgeons, I guess.) Who did it help? No one.
Plaintiff cross examination of the defense expert witness:
Cross examination case 8 defense expert – pdf – 10-10-11
I agree that the handoff of a patient makes that patient high risk. I think that the medical community is discovering that although physician fatigue is worrisome and the institution of 80 hour work weeks for residents is in an effort to help patients, the increase in physician handoffs is likely equally detrimental to the care we deliver to our patients. Although trying to mandate a minimum amount of time speaking about each patient (for instance 3 min. per patient) seems like a good approach to transitions of care, the research I’ve done in this area suggests that physicians should approach handoffs with the aid of mnemonics. Nurses, nuclear engineers, and air-traffic controllers have perfected this format and it is clear through research that mnemonics deliver all of the necessary information about each patient while avoiding the flooding of unnecessary details to the oncoming physician.