The physical exam: it isn't lost on all.

I did a rotation at a pediatric emergency room once as a medical student where I would routinely see pediatric surgeons operate on kids with just the story alone. What I mean is the guy didn't demand a large set of labs or even a ultrasound or CT scan to take a kid to the operating room. Obviously he didn't just take any kid to the OR; he needed to have a certain constellation of symptoms: nausea/vomiting, abdominal pain (specifically at McBurney's point), a postive Rovsing's and/or obturator sign, positive rebound to name a few. I left that month amazed thinking how quickly a kid could end up in the OR after presenting with abdominal pain.

Fast forward a year to my institution where we do not have a pediatric surgeon. Today a kid presented to our institution's pediatric outpatient clinic complaining of abdominal pain with nausea and vomiting. It was recognized there that he most likely had appendicitis and was subsequently transferred to the ED. I picked up the kid after talking with the pediatric resident. He knew the kid had appendicitis and after talking with him I did as well.




I was going to have to transfer this kid to another institution about 90 miles away where a peds surgeon could perform the appendectomy, but I would have to get a confirmatory ultrasound before he could be sent. Transferring the kid to another institution and telling them to prep their OR only to find he did not have appendicitis would be poor form. Fortunately the ultrasound confirmed our suspicions, and fortunately, for the patient, it had not ruptured. We started fluids, antibiotics, pain medications and got on the horn. Much to our disappointment the neighboring hospital said they were at capacity and would not be able to accept the patient.

Seriously?

Anyway, after another hour on the phone we got this kid in route to another hospital via helicopter. I left the hospital remembering my experience as a medical student at the peds ED where kids could be in the OR in less than an hour. My patient today probably spent an hour in the waiting room at the clinic alone. Add that to the time in transit to our ED, the time waiting for an ultrasound and radiologist to read it, and then the hassle of being transferred. From initial presentation to OR will probably easily exceed 7 hours.

Now nobody did anything wrong here. Just everyone doing the best with what they have. I just hope that kid didn't perforate his appendix as he rode to the accepting facility.