Sunday, January 13, 2013

How Nurses Save Lives (and make surgeons look better)

I had seen the lady in the ED at around noon.  She presented with a 1 day history of non specific crampy abdominal pain and nausea/vomiting.  The CT demonstrated a garden variety small bowel obstruction (SBO), likely related to adhesions from a hysterectomy from years ago.  Her labs were all normal and her belly exam was not especially impressive.  Nonetheless, I placed an NG tube and admitted her to the hospital for close monitoring.

In over 70% of cases, an SBO will resolve on its own just with nasogastric decompression, bowel rest, and appropriate hydration.  Typically we will initiate a trial of conservative therapy in these cases.  Lack of progress or outright worsening over the next 24-72 hours then warrants operative exploration. 

I checked on the lady again at around 5:30.  She seemed about the same.  She had some mild LLQ discomfort but no peritoneal signs.  I reviewed the films again.  Her WBC was totally normal, without even a left shift.  I ordered another set of films for the next morning. 

I then received a page from the nurse at around 10:30 that night. 

-Dr Parks, I don't like what's going on with Mrs X
-No?  What's up, I said
-She won't stop screaming.  In pain.  I gave her dilaudid last hour but it didn't touch her.
-That's strange.  Screaming?
-Yes.  You can hear her out in the nurse's station.  It's bothering the other patients.
-Ok.  Send off another CBC and lactate.  I'll be in.
-Thank you.

When I re-examined her at bedside I identified interval development of diffuse peritoneal signs.  She couldn't get comfortable on the bed, writhing in a curled tight ball.  I had her downstairs in the OR within the hour.

A single band of omental adhesion had created a closed loop SBO with volvulus of the mesentery.  The bowel looked like hell, purplish and bruised, on the verge of advanced ischemia.  I quickly snipped the band and detorsed the long segment of intestine.  We covered the wound with warm lap pads and waited.  Five minutes elapsed.  I peeled back the pads with trepidation.  But the purple had faded and the bowel was an angry reddish pink with obvious signs of peristalsis. 

Another hour or two and she might have lost 15 feet of bowel.  She may have died.  The nurse didn't like what was going on up on the floor.  I owe her one. 


jimbo26 said...

Good call ; thats what nurses are there for .

Anonymous said...

Thanks Buckeye, yes we do, but only for a little while longer...


Anonymous said...

Thanks for the recognition Dr B.

Surgeons, take note; most of the time when a nurse calls you "after hours" there is a good reason. Listen. Patiently.

Anonymous said...

Am I the only one who finds this post disturbing?

The nurse called because the patient was screaming and it could be heard at the nurse's station. Would she have called if the lady was not screaming, but suffering quietly? Should not it be the fact the patient's pain had got worse that should have triggered the escalation? At the point where addition pain relieve was requested?