Case Study: Appendicitis

Pc:

16 YOM abdominal pain.

Arrival 21:29

Triage 23:11NEWS 0 (Temp 36.4 BP 123/73 Pulse 87 Resps 16 spo2 96% GCS15) – Paracetomol 1g given

Seen 01:53 by ENPNEWS 0 (Temp 36.9 Pulse 89 spo2 98%) 

Hx:

Attends with father. 1/7 history of right-sided abdominal pain. One episode of vomiting in the evening after eating. Decreased appetite. No feverish symptoms. Pain only. Loose stool yesterday but not today. No relieving factors. Pain worse on some movement. No radiating pain. Pain 7/10. Pain has been constant, no fluctuation in pain. Patient looks well, and not in visual discomfort. 

PMHx:

Nil. Normally fit and well

DHx:

Nil 

NKDA 

SFHx:

Full time education. Lives with mother and father and two foster children. The youngest foster child, aged 2, is currently at BCH with complications due to chicken pox.

O/E:

Alert and orientated, well perfused, GCS15. Right lumbar / Right hypochondriac region pain. Abdomen soft, pain on deep palpation only. Nil distension or guarding. No rebound tenderness. Psoas negative. No pain on palpation of LRQ. No Grey-Turners or Cullen’s sign. Murphy’s sign negative. Skin colour normal. No renal angle tenderness. Bowel sounds present. Urine dip normal.

Bloods sent 02:15 – LFT, U & E, FBC, Amylase and CRP

Bloods back 03:30 – CRP 10, WBC 14.66, Neutrophils 12.96 Amylase 69

03:30 – NEWS 1 (Temp 37.3 Pulse 96 spo2 98%) 

Refer to Surgeons 03:45– SHO not aware 16 year olds are seen at BRI. SHO is concerned patient is only 16, doesn’t think appropriate for patient to go to ward. Passes phone to SPR. SPR says not appropriate for 16 year old to be on adult ward. She states the patient will be seen at 08:00 on A609 with a plan to perform an ultrasound. Patient to be sent home in the interim with safety-netting advise. Surgeons will not come and review patient prior to discharge.

I was unhappy with the plan, discussed with the patient and his father, who was also reluctant to drive an hour home to Weston to return an hour later. Called SHO and said family not happy with being discharge. Was advised he would speak to the SPR and get back to me. Discussed with the Site Team and ED Reg as age shouldn’t be a factor. Patient lives an hour away so turn-around time too short. Spoke with Surgical SHO again and advised patient not suitable to go home and wound need a bed. Discussed with SPR and agreed for patient to be admitted. 

DTA 04:00 – Advised patient and father of DTA, patient states he has just vomited again in the toilet and is feeling worse. Patient still looks well, not in visual discomfort. Will arrange more analgesia and repeat OBs.

Prep for ward 04:30 – Repeat Obs priorto ward transfer (NEWS 4 – spo2 100% BP 104/55 Pulse 140 Temp 38.8  Resps 15)  Gained IV access, gave IV fluids, IV ABX, Lactate 3.7 on VBG, Cultures taken and sent. Spoke with Surgical SHO, will now come and review patient. Patient now flushed in appearance, blotching and blanching skin, pyloerections, shivering violently, looks unwell. 

Transferred to Resus at 05:00 (NEWS 5 – spo2 98% Temp 39.6 Pulse 138 BP 120/72 Resps 18) – 14g cannula, fluid challenge. Seen by surgical SPR and SHO. CT abdomen arranged, consented for surgery.

06:00 – (NEWS 12 spo2 100% (on 02) Temp 39.6 Pulse 138 BP 76/32 Resps 22) – Repeated WBC 3.76 CRP 12

CT Abdomen 06:15 – “There is an enlargement of the appendix measuring up to 15 mm withseveral appendicoliths. CT features consistent with an appendicitis with appendicoliths. A splenomegaly is also noted.”

06:45 Transferred for emergency surgery.

Post surgery patient spent over 2 weeks in hospital including a week on ITU.

Things we did well:

  • Escalated appropriately
  • Transferred out of Fast Flow to resus as soon as deterioration was evident
  • Made appropriate referral to speciality
  • Followed sepsis pathway quickly
  • Good advocate for patient and family with decision to keep them in
  • Gave analgesia at triage

Things that weren’t done as well as could be:

  • 1 hour 42 minutes to be triaged (complicated patient with police + patient’s being taken to ward + 35 patients arriving in an hour, in an already busy department + no coordinator due to queuing)
  • 4 hours 24 minutes to be seen initially by ENP
  • 6 hours 15 minutes to be referred to specialty
  • Almost sent home by surgeons without being reviewed
  • Only 1 set of OBs in 4.5 hoursin the department prior to being seen.
  • Delays in being accepted by specialty due to confusion about age criteria.
  • Patient’s age and vague history of pain led to some complacencyabout how unwell the patient could have been.

Learning Points:

  • A 16 year old is still a child. They can compensate for much longer than an adult resulting in a rapid deterioration. NEWs score 1 to NEWs score 12 in less than 2 hours!
  • Triage should not be delayed that long. When ambulance queuing, the duties of the Fast Flow coordinator need to be clearly handed to someone else. Extra staff must triage for patient safety
  • Should suspect conditions even with atypical presentations, especially in pediatrics. Poor historians can lead you away from the source of the problem. Look at age and most likely causes and exclude them
  • Always challenge specialty decisions if you think they compromise patient safety
  • If you have referred to a specialty, don’t allow the patient to be discharged without being reviewed by them. You referred to them for a reason, lack of beds is not a reason not to be physically seen before discharge
  • Always be the advocate for your patient. Would you be happy to be sent home with your child still in pain? If the answer is no, don’t send home someone else and their child who is still in pain
  • One of the recommendations that came out of the 16 year old meningitis case a couple of years ago, was that ALL unwell under 18s should be reviewed by a paediatrician. This is obviously not practical within our department but has made me very wary of unwell 16 and 17 year olds. I would advise consultant input(Reg at night) at the earliest opportunity and definitely before considering discharge or problems with onward referral.

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