seat belt signs". She was also was quite tender on abdominal exam. Her labs revealed an elevated white blood cell count, in itself not necessarily a concerning thing as young trauma patients with broken limbs will often mount a reactive leukocytosis. But her abdominal exam bothered me. I reviewed the CT with the radiologist. She didn't see anything unusual. So I repeated the CT and the blood work 2 hours later. Her WBC count was now over 20. The CT scan, however, was again read as "normal". When I examined her, she had frank peritonitis.
I took her to the OR and found she had perforated her proximal jejunum. Enteric contents were actively leaking into her peritoneal cavity. Everything else looked OK. We lopped out the damaged intestinal segment and put everything back together again. She did very well afterwards.
Blunt injury to the intestinal tract is a terrifying diagnosis in the world of trauma surgery. The CT image you see above is from the young lady's 2nd scan. What you don't see is anything that would ordinarily mandate an operation. There is no free air. No ascites. No obvious evidence of bowel injury. You just have to be patient with these cases. Examine the patients frequently. Don't be comfortable with negative CT scans. It also helps to have a firm grasp on what is meant by the term "peritoneal signs".
These are the cases where you simply have to know what the hell you are doing, individually. Collaborative care won't get you anywhere. You won't receive an award for just removing the patient's foley after 24 hours. Your Accountable Care Organization won't send you an Olive Garden gift certificate for limiting the total inpatient costs. It's all on you, buddy. Prom night 2012 is ten months away.