Moderator EMEDPA Posted September 8, 2013 Moderator Share Posted September 8, 2013 read this: http://www.ncbi.nlm.nih.gov/pubmed/22569747 interesting. maybe something we will see over the next few years as a way to cut costs? Link to comment Share on other sites More sharing options...
chiefPA Posted September 8, 2013 Share Posted September 8, 2013 Very interesting Link to comment Share on other sites More sharing options...
tariesen Posted September 9, 2013 Share Posted September 9, 2013 Interesting indeed. December of 2011 I presented to the emergency room with no appetite and diffuse abdominal pain x 3 days. After several hours of checking things off the differential diagnosis list, they finally did a CT scan and found a large abscess where my appendix was supposed to be - dx = ruptured appendix. I was admitted and had a CT-guided drain placed the next morning and was placed on IV metronidazole and levofloxacin. The attending surgeon said that the emerging treatment for cases like mine were to treat with systemic antibotics for ~30 days and then assess via CT scan whether any of the appendix remained. Any attempt at surgery at the time would be difficult and could lead to complications given the amount of inflammation, etc. I was discharged four days later with a month's supply of oral metronidazole and levofloxacin. Follow-up CT showed a small portion of my appendix remained. I had it out via laparoscopy that May. Piece of cake. My question would be how the provider would be able to assess the likelihood of rupture upon presentation to the ER - if it got to that point. My case may have been unusual, in that diffuse abdominal pain x 3 days was my only major symptom (my tolerance for pain is high, I suppose). Would the approach outlined in the article increase the risk of bacteremia in patients that do rupture? Link to comment Share on other sites More sharing options...
ajnelson Posted September 10, 2013 Share Posted September 10, 2013 Along the same lines, many of the surgeons I work with don't take these guys right to surgery anymore. They will let them sit a few hours, re-evaluate and then take them to surgery. (I work mostly overnights, so they aren't coming in or calling in the OR team in the middle of the night, just waiting and putting these patients on the OR list for the next day). Link to comment Share on other sites More sharing options...
paprospect24 Posted September 10, 2013 Share Posted September 10, 2013 Glad to see this catching on. Been saying this for a while. That and the appendix is not a "useless" organ. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 10, 2013 Author Moderator Share Posted September 10, 2013 I heard an english surgeon a while ago say "think of mild appendicitis as right sided diverticulitis". Link to comment Share on other sites More sharing options...
medic25 Posted September 10, 2013 Share Posted September 10, 2013 http://pulsemagazine.org/ Interesting essay by a PA who had an appendicitis prior to having health insurance; he ended up using the literature to support antibiotics only rather than going bankrupt by having surgery. Link to comment Share on other sites More sharing options...
Just Steve Posted September 10, 2013 Share Posted September 10, 2013 It's been years and my memory may be foggy but I am pretty sure IV antibiotics was the standard of treatment for suspected appy while underway with Uncle Sam's Canoe Club (Navy), especially if evac to a surgical capable platform was not available. If I recall correctly, which I may not, it was not uncommon for an appy to calm down and behave itself after a few rounds of metro. As I started to hang out with surgeons, it seems they were the ones pushing for removal, not the medical docs. Maybe I'm just a round or two of drinks too far in to be posting. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted September 10, 2013 Moderator Share Posted September 10, 2013 It's been years and my memory may be foggy but I am pretty sure IV antibiotics was the standard of treatment for suspected appy while underway with Uncle Sam's Canoe Club (Navy), especially if evac to a surgical capable platform was not available. If I recall correctly, which I may not, it was not uncommon for an appy to calm down and behave itself after a few rounds of metro. As I started to hang out with surgeons, it seems they were the ones pushing for removal, not the medical docs. Maybe I'm just a round or two of drinks too far in to be posting. Liquid courage, eh Steve :D Link to comment Share on other sites More sharing options...
Moderator ventana Posted September 10, 2013 Moderator Share Posted September 10, 2013 It's been years and my memory may be foggy but I am pretty sure IV antibiotics was the standard of treatment for suspected appy while underway with Uncle Sam's Canoe Club (Navy), especially if evac to a surgical capable platform was not available. If I recall correctly, which I may not, it was not uncommon for an appy to calm down and behave itself after a few rounds of metro. As I started to hang out with surgeons, it seems they were the ones pushing for removal, not the medical docs. Maybe I'm just a round or two of drinks too far in to be posting. on a side note with tongue in cheek.... No kidding.... you send a patient to a surgeon and they want to do surgery??? no way....... the reasonto bring this up is not to pick o steve, but instead to link to two very recent threads..... 1) new grads in ER---- if your olny ddx for abd pain is appy and you get ct ad surgery consult on most abd pains..... you are going to have some unneeded surgeries... 2) why I likee primary care----- who you refer to and how much you can do on your own has a DIRECT EFFECT on the outcome.... to truly effect your patients lives is an amazing job and gift! 3) with this amazing influence on health care should we not have a CAQ and fellowship for primary care (and before everone says that is PA school - do you really think they would make a doc do 7 years of trainning if it only needed 6 semesters?) I suspect somewhere in the middle is the truth..... Link to comment Share on other sites More sharing options...
sk732 Posted September 10, 2013 Share Posted September 10, 2013 When I was on my gen surg rotation in 2008, there was a trial going on based upon a study done in China of treating appendicitis with IV and then PO antibiotics - generally the early ones we were starting on metronidazole and one or two others and treating as outpatients...apparently the Chinese have been doing it for sometime now. The last couple I've had in my office or the ER were pretty far along to go this route - once had outright ruptured and the other was well on the way. Based solely on health care dollars cost, I'd say it's still a promising research idea to treat non-surgically IF CLINICALLY INDICATED - obviously patient condition trumps things, since a belly full of pus should probably be cleaned out. We know a good surgeon, like a good mecahnic, can get paid a fair sum for what to some is about 3 minutes work...we also know that a good surgeon won't cut unless they think it's needed - in this instance, sounds a bit like they sometimes need convincing that "the only way to heal is with cold steel" isn't always the case. My $0.02 SK Link to comment Share on other sites More sharing options...
SocialMedicine Posted September 10, 2013 Share Posted September 10, 2013 did this guy study the literature? he read something fast in an ED it sounded like he did not study the article I believe recurrence rates are much higher in people who treat with antibiotic Link to comment Share on other sites More sharing options...
Just Steve Posted September 10, 2013 Share Posted September 10, 2013 Ok...I lied. Last night I wasn't into the cocktails, I was just too lazy to do a literature dive. I had been studying for the boards all day and wanted a drink, but there are more pressing needs for my gray matter at this time other than serving as a hospitality suite for distilled grains. While I have another day of studying ahead of me, I just tapped in a few key strokes to verify that I indeed, am not losing my mind. http://europepmc.org/abstract/MED/2119012 http://www.ncbi.nlm.nih.gov/pubmed/21348022 The first link is a study published out of UW in 1990. I was serving on a non surgical capable ship in 1995, particularly off the coast of Liberia while we put Marines on shore to provide security for the American Embassy there during a little uprising of the locals. As part of the amphibious battle group, we did have an LHA with us, which has a surgical suite, but we were not always within a quick ambulance ride away and helicopters were not always an option "at the ready". In other words, we were in a position where we may have had to babysit our own patients for awhile before turfing them off. The second abstract does mention a recurrence rate of 15.9%. However, in my opinion, if faced with overwhelming medical bills, or if in a less than ideal location for surgery, I would totally roll the dice with some antibiotics and hope to be in the 85% of patients who don't have a recurrence. Or if I do within that 12 month window, I am in a physical or financial place that is more suited for definitive treatment at that time. Along the vein of surgeons vs. med docs... "never let the skin stand between you and the diagnosis". Before every critical access hospital in Podunk Nowhere town had a 128 slice CT scanner, we sometimes opened people up and found out our interpretation of the physical exam and lab findings were wrong. While I am a brand new PA, I started medicine in 1988 and have watched the evolution of technology that has allowed medicine to grow by leaps and bounds in the world of diagnostics and procedures. When I started, it was quite common to see the medical side of the house practice medicine based on their gut instinct, almost going to the point of hiding their patients from the surgeons, believing they could cure them like an episode of the TV show "House". Now, with imaging, that game of "who's got the right diagnosis" between medical disciplines has vastly been leveled out. So when I saw that story of the PA making news for treating his appy with meds vs steel and bright lights, I was thinking "what's the big deal?" Of course, we could get into a discussion of the side affects of antibiotics, but that is for another day. Anyways...back to the Kaplan review. Wish me luck Link to comment Share on other sites More sharing options...
Guest Paula Posted September 11, 2013 Share Posted September 11, 2013 on a side note with tongue in cheek.... No kidding.... you send a patient to a surgeon and they want to do surgery??? no way....... the reasonto bring this up is not to pick o steve, but instead to link to two very recent threads..... 1) new grads in ER---- if your olny ddx for abd pain is appy and you get ct ad surgery consult on most abd pains..... you are going to have some unneeded surgeries... 2) why I likee primary care----- who you refer to and how much you can do on your own has a DIRECT EFFECT on the outcome.... to truly effect your patients lives is an amazing job and gift! 3) with this amazing influence on health care should we not have a CAQ and fellowship for primary care (and before everone says that is PA school - do you really think they would make a doc do 7 years of trainning if it only needed 6 semesters?) I suspect somewhere in the middle is the truth..... Agree with you Ventana.....a primary care fellowship or residency. We would then be like the GPs (who are a dying breed but they have independence and no one supervising them!!!). My Sp is a GP who never finished his residency.......If I had an 18 month primary care fellowship we would have the equal number of years of education in medicine. Link to comment Share on other sites More sharing options...
skyblu Posted September 11, 2013 Share Posted September 11, 2013 Very interesting. I recently missed an appy on a 22 year old. He presented with mostly epigastric pain and vomiting, no diarrhea or fevers, WBC count was 12, otherwise normal labs including ESR. He had an endoscopy one year (to the day!) prior when he presented with identical symptoms and had found mild to moderate gastritis. he was non compliant with PPI's or diet. He was challenging to examine because he was...well, a drama queen. I seriously barely touched the guy and he was screaming in pain. I explained repeatedly that although uncomfortable, it was very important that I try to find where most of the pain was coming from. Still, no McBurney's tenderness, nothing peritoneal, and negative Rovsing's, psoas and obturator signs. I gave him IV fluids, Zantac, Zofran and 0.5 of Dilaudid, which resolved his symptoms completely. I observed him int he ED for 6 hours with serial abdominal exams that were completely negative. So I discharged him without a CT. I also saw no indication for abx. Came back the next day with recurrence of symptoms, he was scanned, and he had an appy. I felt really terrible about missing it, but when I review my chart, I honestly wouldn't do anything differently. My sup doc actually said, "That's good that you missed it. It means you don't scan every single young person belly pain you see." But yeah, if I had felt like it was a surgical abdomen, surgery would have scanned him. Our pedi surgeon almost never scans, but our adult ones don't seem to take anything without radiographic evidence. And they will operate, of course they will. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted January 20, 2014 Moderator Share Posted January 20, 2014 Wanted to bring this back to the top, as I had a patient this past weekend (I was covering our observation unit)- this 50's-ish guy with no past hx of anything came into the ED, got scanned and was read as acute uncomplicated appy, but was rather comfortable-appearing; he was placed in the Obs unit, got abx and saw surgery the next day. Surgeon came and saw him....and recommend PO abx and outpatient follow up in his office. NO OR. Floored me, but there it was. We discharged him home with abx- with very strict instructions to return if he was any worse- and off he went. I haven't gotten any "bad emails" yet, so I'm assuming he is doing okay Link to comment Share on other sites More sharing options...
RetNavyPAC Posted January 21, 2014 Share Posted January 21, 2014 I was serving on a non surgical capable ship in 1995, particularly off the coast of Liberia while we put Marines on shore to provide security for the American Embassy there during a little uprising of the locals. As part of the amphibious battle group, we did have an LHA with us, which has a surgical suite, but we were not always within a quick ambulance ride away and helicopters were not always an option "at the ready". In other words, we were in a position where we may have had to babysit our own patients for awhile before turfing them off. Steve, what 'gator freighter were you on? I served time during two pumps to the Med/IO and Persian Gulf in '87 & '88 as a green-side HM3 on the USS Saginaw (LST-1188) and the USS Trenton (LPD-14) Link to comment Share on other sites More sharing options...
RetNavyPAC Posted January 22, 2014 Share Posted January 22, 2014 read this: http://www.ncbi.nlm.nih.gov/pubmed/22569747 interesting. maybe something we will see over the next few years as a way to cut costs? Emed - I think you are correct. This is tangentially-related to the thread, but in the next 5-ish+ years when a more payment for healthcare may be a capitation model we'll get paid for keeping patients OUT of the hospital unless absolutely necessary, and the ones we do admit will be heavily scrutinized. It's a paradigm shift (God how I hate that phrase - but it does work), but if you think about it we admit patients to the hospital NOT because they need to be in the hospital, but that they require services that, currently, are available only IN the hospital. Once healthcare systems apprehend this fact, and the savings (not only in cost but morbidity and mortality), and direct more resources to case management and outpatient in-home services we'll probably admit many fewer patients than we do now (what we'll call the 'good ol' days). :-) Link to comment Share on other sites More sharing options...
JP86 Posted February 24, 2014 Share Posted February 24, 2014 I read a study this past year saying how in Europe and some of Asia this is the standard of care for uncomplicated Appy. They said not to expect it in the United States anywhere in the foreseeable future as we are stuck practicing defensive medicine in our lawsuit happy society. Very interesting.I recently missed an appy on a 22 year old. He presented with mostly epigastric pain and vomiting, no diarrhea or fevers, WBC count was 12, otherwise normal labs including ESR. He had an endoscopy one year (to the day!) prior when he presented with identical symptoms and had found mild to moderate gastritis. he was non compliant with PPI's or diet.He was challenging to examine because he was...well, a drama queen. I seriously barely touched the guy and he was screaming in pain. I explained repeatedly that although uncomfortable, it was very important that I try to find where most of the pain was coming from. Still, no McBurney's tenderness, nothing peritoneal, and negative Rovsing's, psoas and obturator signs.I gave him IV fluids, Zantac, Zofran and 0.5 of Dilaudid, which resolved his symptoms completely. I observed him int he ED for 6 hours with serial abdominal exams that were completely negative.So I discharged him without a CT. I also saw no indication for abx.Came back the next day with recurrence of symptoms, he was scanned, and he had an appy.I felt really terrible about missing it, but when I review my chart, I honestly wouldn't do anything differently. My sup doc actually said, "That's good that you missed it. It means you don't scan every single young person belly pain you see."But yeah, if I had felt like it was a surgical abdomen, surgery would have scanned him. Our pedi surgeon almost never scans, but our adult ones don't seem to take anything without radiographic evidence. And they will operate, of course they will. That's interesting because I too had a patient who presented as epigastric abdominal pain that ended up being an appy. However, I did scan the person because their WBC was near 18 and they had a pretty considerable amount of guarding with their Epigastric to RUQ exam. It was after hours and US was not available to us, so I did a CT with IV only contrast in all honestly trying to rule out ruptured gastric/peptic ulcer vs acute cholecystitis. The radiologist calls me and bet me I'd never guess the diagnosis and said that it was acute appendicitis with the location of the appendix being in the "perihepatic space." He said he has only seen one in that location a couple times. You just never know! And kudos to not overscanning...it's tough not to do in this country full of ambulance chasers! Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 24, 2014 Author Moderator Share Posted February 24, 2014 I had an appy a few years ago with LLQ pain...I did the ct for diverticulitis r/o. bowel was malrotated with a + appy. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 24, 2014 Share Posted February 24, 2014 This treatment recommendation has been the closet step-child for years after we noticed those across the big pond had been having good results for years. I've wondered for years why we haven't parked these folks in an obs unit (assuming the particular ED had one) and give them IV abx. (an actual indication for abx.!). This idea probably won't work out though long-term since the "spirits" PAC will probably argue that the usage of metronidazole will adversely impact their alcohol sales. As an aside, instead of parking cellulitis cases in the ED a decade or more ago (no obs unit) we'd heplock folks (discharge in place), dose them with Ancef, and then have them come back 12 hours later for repeat dosing, and would do so over an entire weekend to avoid admission. As pointed out previously, as long as you have what you consider to be a reliable patient/family, provide them warning signs to warrant early return and let them go. With laparoscopy, I'd like to know if overall appy's are increasing or decreasing in number? Link to comment Share on other sites More sharing options...
ajnelson Posted February 24, 2014 Share Posted February 24, 2014 I had an appy a few years ago with LLQ pain...I did the ct for diverticulitis r/o. bowel was malrotated with a + appy. I had a 30yo or so guy who came in with LLQ pain, had some mild guarding. Scanned him only because of the guarding, and we have seen some younger people with pretty bad diverticulitis. Ended up with a left sided appy... Link to comment Share on other sites More sharing options...
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