Sunday, August 18, 2013

Abdominal pain = Surgeons



There is an interesting rule at our hospital that anybody with abdominal pain is seen be a surgeon before anybody else. The reason for this is that most causes of abdominal pain are dealt with by surgeons. This is thought to stop patients coming in under another team and then having a serious surgical diagnosis missed. It is also about sharing out the inpatient work load as the physicians are very busy and is unfair them looking after all the non operative chronic abdominal pain. It might also have something to do with grumpy surgeons refusing to see patient's that they deem "not surgical".

 This is very noble and a good idea in theory but the problem comes when the abdominal pain is due to something surgeons aren't good at managing. Once a patient has your name on them, it is very hard to get another person's name next to them, even if they'd be better off with them.

Also not every patient with abdominal pain necessarily has a surgical problem. Below is a list of diagnoses that I have actually seen in patients referred to myself as the surgical on call.

- Inferior MI - Epigastric pain and sweating
- Right lower lobe pneumonia - Right upper quadrant pain
- DKA - central abdominal pain and sweating
- Pre-eclampsia - Right upper quadrant pain 3 days post partum. This was made even worse by her having a BP of 160/100 and no platelets which no-body put 2 + 2 together.
- Septic Hip - Right iliac fossa pain (and a limp!!!)
- Ectopic - Right iliac fossa pain + vaginal bleeding + pregnancy test
- Labour - Yes, I've actually had a patient referred to me with "Abdominal mass, amenorrheoa and intermittent abdominal pain. ?tumour". 4 hours later they gave birth.

I haven't managed to get the Porphyria patient yet. But all the others are true.

Furthermore, the converse is true. Many patient's pigeonholed into being "medical" later turn out to have a surgical problem. The below patients are all patient's I have been referred by the medical on call and needed surgery.

AAA - collapse ?cause
Pancreatitis - confusion ?cause
Boerhaave Syndrome - Chest pain ?ACS
Necrotising Fasciitis - Leg swelling
Small bowel obstruction - Vomiting

Here is an interesting idea. Why can't we diagnose our patients and send them to whoever the patient needs. Medicine is not all about fitting people along a pathway or fitting in a box. Not every abdominal pain needs a surgeon and many patients without abdominal pain do.

This isn't a moan about A&E doctors. I've done a couple of locums in there and I don't envy their job at all. It's the politics behind the making up of arbitrary rules of who sees whom that annoys me. Perhaps if we were all a little more trusting and a little more keen to take over cases that come our way, this set up wouldn't occur.

10 comments:

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  2. interesting... the referral of patient in labour was really shocking... hopefully i will become a good and reliable doctor later on

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  3. "AAA - collapse ?cause
    Pancreatitis - confusion ?cause
    Boerhaave Syndrome - Chest pain ?ACS
    Necrotising Fasciitis - Leg swelling
    Small bowel obstruction - Vomiting" this is so helpful tips.

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  5. There are plenty of reason you can find in abdominal pain.

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  8. It is amazing how often I see nurses and those triaging patients never putting their hands on the patient. Never listening to the abdomen and never palpating and checking for rebound tenderness or pulsating or masses. They simply assume based on the location of the pain or age/sex of the patient as to what is "probably" wrong. How irresponsible.

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  10. Nice sharing. No doubt you shared a great topic. One should always go and see a surgeon if he gets into such pain.

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