Listen to the nurses

Shares

A 9-year old male was brought to the ED after fainting in school. Upon awakening in the morning, he vomited twice, but he was sent to school. At school, he vomited three more times and continued to feel ill and weak. He fainted briefly, which prompted the school nurse to call his mother who brought him to the emergency department.

There was no seizure activity witnessed. He was noted to have a poor appetite and low grade fever for the past week. His past history was significant for acute post-streptococcal glomerulonephritis (5 years ago, now resolved) and an injury to his left iris.

 

Exam findings

T36.8 (orally), P110, R24, BP 136/78, oxygen saturation supine in room air 95%. He was a husky youngster of moderate obesity (weight 72 kg). No acute distress noted. Head without signs of trauma. Eye exam positive for the irregular left pupil due to his iris injury. His optic discs were sharp. EOM’s full. TM’s normal. Oral mucosa moist. Neck supple, no adenopathy.

Heart regular without murmurs. Lungs clear. Breath sounds somewhat distant but consistent with the moderate obesity. Abdomen flat, soft, non-tender, active bowel sounds. Liver and spleen edges not palpable. No hernias. Normal testes. Capillary refill time <2 seconds. Visible perfusion good.

Color slightly pale. Neuro: Speaks well. Facial function good. Uses extremities well.

A quick glucose check showed a normal value.

 

Progress

By the time of this exam, he was feeling much better and wanted to go home. He denied any headache, dizziness, weakness, or nausea at this time.

His mother commented that his color had improved since the time she picked him up from school. He was not pale at home. The diagnostic impression at this time was that of a viral infection with pallor due to the vomiting. His mother was told that it is not uncommon for a person to faint during a flu-like illness. Since he was feeling much better, he was about to be discharged from the ED. An ED nurse approached the physician and told him that she thought the patient’s abdomen appeared distended. She also suggested that an abdominal series be obtained. A second ED nurse agreed.

The physician went back to the patient to re-examine his abdomen. The abdomen appeared flat. Even after looking specifically for any distention, none was appreciated. He continued to have active bowel sounds. There was no tenderness and no other abnormalities could be detected.

 

More examination

Repeat VS: T98.9 (oral), P118, R24, BP 120/80, oxygen saturation 98% in room air (supine).

At this point, the patient seemed to be stable and the physician was confident in his diagnosis. After the re-evaluation, the nurses made no further comments about the abdominal distention.

What would you do at this point?

Because of the suggestion of the two experienced E. nurses, the physician elected to order the abdominal series to evaluate the possible abdominal distention that only these two nurses could see.

Supine view

Upright view

 

Note that on the upright view, a pair of hands are holding him by the pelvis suggesting that he had difficulty sitting up on his own. The patient was too large to fit his entire abdomen on the film. The diaphragms were not visible . Therefore, an AP CXR was done to view his diaphragms.

AP film

Since the radiographs were obtained to investigate abdominal distention in a patient with vomiting, radiographic signs of a bowel obstruction should be the most important things to look for. These radiographs show a good distribution of gas throughout the abdomen. There are no large air fluid levels. When viewing abdominal radiographs, it is common to ignore the bony structures and the lungs. Significant findings in the bony structures of the abdomen that may be missed include vertebral compression fractures, dislocated hips (congenital), metastatic lytic lesions, bone cysts, etc.

Pulmonary infiltrates are commonly missed if the lung portions at the top of the abdominal film are ignored. Abdominal radiographs are commonly ordered to investigate abdominal pain. Since lower lobe pneumonias are commonly the cause of abdominal pain, always remember to examine the lung portion of the abdominal films or obtain a CXR to adequately visualize the lung fields.

In this case, this abdominal series revealed a right pleural effusion. This can only be seen on the AP chest view. If our patient were smaller and a separate CXR was not done, this pleural effusion may only have been visible at the very top of the film where a blunted costophrenic angle may have been noted. Both hemidiaphriagms appear abnormal in contour. The lateral portions of the hemidiaphragms appear to be higher than the medial portions (more obvious on the patient’s right than on his left). This indicates the presence of subpulmonic effusions. On this AP view, there is a visible effusion on the patient’s right only. But the appearance of the diaphragms suggest bilateral pleural effusions. Bilateral decubitus films were then ordered.

These images show bilateral pleural effusions, larger on the patient’s right. After noting the pleural effusions, the possibility of ascites was raised. Minimal peripheral edema was noted. Since the patient had a previous episode of acute glomerulonephritis, the possibility of renal disease was investigated.

His urinalysis and renal function studies were normal. His blood count failed to show any abnormalities. Examination of the pleural fluid revealed malignant cells. Bone marrow studies confirmed the diagnosis of Burkitt’s lymphoma.

This physician was grateful to the two nurses who had suggested ordering the abdominal series. Even after the patient was hospitalized, other examiners failed to appreciate any abdominal distention. Only these two ED nurses could see it.

In the orientation manual for our ED, students and residents are told, “Our ED nurses are very experienced. If they suggest anything to you, you should strongly consider carrying out their suggestion.” Additionally, all nursing notes should be read during a patient’s evaluation. Nurses will often write down observations or historical items that the patient fails to bring to your attention. Ignoring an ED nurse’s assessment is a pitfall that should be avoided.

Print Friendly

About 

Prof Loren Yamamoto MD MPH MBA. Professor of pediatrics at the University of Hawaii and a practising pediatric emergency doctor in Honolulu. | Contact | View Loren's DFTB posts

3 Responses to "Listen to the nurses"

  1. […] Yamamoto of Don’t Forget the Bubbles reminds us why it is always good to Listen to the Nurses. His story of a nurse picking up an impossibly subtle physical exam finding led to some interesting […]

  2. Todd
    Todd 3 years ago .Reply

    I completely agree with concept of listening to and addressing any nursing concerns about a patient, especially if those nurses are experienced. I too have been saved by a nurse picking up something I’ve overlooked.

    Unfortunately, I don’t think this case demonstrates this concept. What this case does demonstrate is that if you run enough tests, eventually you’ll come across an incidental finding which (though often not) can be treatable.

    Abdominal distention, in isolation without pain/vomiting/fever/other symptoms, is incredibly subjective and unreliable. As evidenced by the physician reevaluation, the patient is noted to have a completely normal exam. Given the benign exam, I’m not convinced further imaging was warranted.

    Plain abdominal films are really only indicated in 3 scenarios: evaluation for obstruction, evaluation for free air, and evaluation for foreign body. They are expressly NOT recommended for vague or undifferentiated abdominal pain. Perhaps if the concern was to evaluate for obstruction in a distended abdomen, I’d be more convinced. However, the post does not make any mention of evaluating for obstruction. If any imaging was indicated in this case, it was not plain abdominal films. I will admit I find it frustrating that practitioners (especially within pediatrics) continue to order abdominal x-rays, exposing children to radiation and increased cost, when there is very limited evidence of their utility.

    Last, there is no discussion in the post describing, ultimately, how the nurses’ detection of abdominal distension is related to the abnormal finding: pleural effusions. I will buy that lower lobe pneumonias/effusions can cause abdominal pain, but this is not what’s presented. What’s presented is that the finding of abdominal distension led to the pick up of pleural effusions. There is no pathophysiologic basis for this connection.

    The case concludes with “only two ED nurses could see it.” Again, not at all to disparage our nursing colleagues (whom I respect and trust greatly), but they are not supernatural and do not have the a mystical 6th sense. Neither do we. This was simply a case of dumb luck. I’m very happy for the patient that the stars aligned, but it is by far the exception. The vast, vast, vast majority of abdominal x-rays are nonspecific and unhelpful. This case could be repeated a thousand more times, and the outcome would likely be discharging the patient with expectant management and improvement without specific treatment.

  3. Ben Symon
    Ben Symon 3 years ago .Reply

    Firstly I would like to thank all the nurses over the years who have carried me through difficult situations and pointed out findings I may have missed, they have bailed me out many times over the years! I strongly agree with the spirit of this article! I’m also amazed at the subtlety with which some emergency nurses can let you know of their concerns while never making you feel stupid, a simple comment like “that’s an interesting place for a fracture” can transform your approach to a case.

    Secondly however, I would like to emphasise that ‘always listen to the nurses’ should not be equivalent to ‘always do what they say’, which I think is somewhat implied in this article.

    I take what any experienced nurse says to me extremely seriously, but just doing what someone else tells you to do without checking that you agree with their assessment will not develop you as a doctor and in the end will not satisfy the nursing staff either. I’ve found most experienced nurses don’t want an obedient doctor, they want a doctor who respects them, who works with them as a team player and who acknowledges and seriously considers their concerns. If you seriously think about their concerns, assess the patient and feel that you disagree with the suggested management and can explain clearly why, this will be appreciated even if you don’t necessarily agree.

    I remember when I was a new Reg in NICU, I heard a very senior NICU nurse pay an interesting compliment to my supervising Reg. “It’s great having you on”, she said, “You really listen to us, but you don’t just do what we say.”. The nurse clearly appreciated that the Reg had developed her own sense of critical thinking as well. I have always carried that comment with me.

Leave a Reply