Daniel, et al,
I appreciate your thoughts regarding the lack of sensitivity of humans to
evaluate appendicitis. I feel much the same way, in spite of having done 2
years of surgical residency before my EM residency. I think all of us must
admit that we are often guessing, hoping to be right.
However, it then brings up the next question of relevance. If the patient
you describe had been sent home as a nonspecific abdominal pain, would it
have made a difference? How many cases are being found that would have
resolved without consequence? One of my urology colleagues hates that we are
doing CT for abdominal trauma, instead of IVP, because we are finding so
many more cases of renal injury. He says that puts him in the position of
having to decide what to do, whereas with IVP, if an injury showed up you
knew it was likely to be significant enough to need surgery.
I guess you could make the argument that it is better to have the
appendectomy while healthy, rather than when more in extremis. This would be
consistent with cholelithiasis/biliary colic, in which we all agree that the
patient should have cholecystectomy before cholecystitis sets in.
I realize I am making both sides of the argument. That is because I don't
know what the real answer is. I would be interested in other opinions.
John L. Meade, MD, FACEP
Chief Executive Officer
Emerald Healthcare Group, P.A.
Doctor's Resource Group, Inc.
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]]On Behalf Of Daniel E. Kates
Sent: Wednesday, March 22, 2000 05:32
To: [log in to unmask]
Subject: Re: Appendicitis
I appreciate your comments regarding surgeons, especially surgical
residents, because my experience has been the same. Where I trained the
surgeons seemed to do anything to NOT have to operate on someone.
Something that obviously baffled the rest of us in the hospital since we
thought the purpose of their training was to do surgery. Almost
invariably, by the time the case made it to the senior level resident or
attending they were clearly in agreement with the ED staff and the
patient went to the OR or at least got admitted and observed.
With the advent of the use of CT for r/o Appy, I have become more amazed
at how few appy's present "classically". Our hospital has the most
modern spiral CT scanner on the market. Literally seconds to do a
complete abdominal CT. Our Radiology Department protocol for the last
6-7 months for cases of r/o Appy is a completely noncontrasted pelvic CT
(they call it pelvic, but it actually goes higher up). I have been
amazed at how many confirmed appy's I have had in cases that were
otherwise not "textbook" cases. For example, I had a 20 year old female
yesterday that presented with a 15 hour history of RLQ pain. She denied
fever, denied nausea or vomiting, denied anorexia, or any other
symptoms. She was afebrile in the ED and appeared in no distress at all.
She was hungry and anxious to be told she was fine. Her exam revealed
moderate RLQ tenderness without guarding or rebound. Her WBC was 7.8 and
all other labs were normal. Well, if you go by the opinion of many of my
surgical colleagues, this patient couldn't have appendicitis. They will
tell you that she is afebrile, is hungry, has no peritoneal signs this
far into the course, has a normal WBC, etc., etc., etc.
Well, I sent her for our spiral CT "Appy study" and 10 minutes later I
received the report showing a confirmed appendicolith, moderate swelling
of the wall of the appendix, and the classic streaking of the
periappendiceal mesenteric fat consistent with inflammation of the
So, as you said Mike, I frequently trust the CT more than I do the
subjective nature of human hands.
Daniel E. Kates, M.D.
Department of Emergency Medicine
Thunderbird Samaritan Medical Center
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