RURAL MEDICINE INTEREST GROUP
In the Patient’s Best Interest Robyn Hitchcock, MD FAAEM, Founder and Chair of Rural Medicine Interest Group
I
'm working at a critical access facility, and shortly after my 7:00am shift started, a 36-year-old woman rolled in the door complaining of sudden onset of right-sided abdominal pain and a syncopal episode at home. She’s gray, diaphoretic, and a little groggy. Blood pressure is 88/40, heart rate 128. Looks sick, looks shockey.
She doesn’t think she is pregnant and is using condoms for birth control. Denies any symptoms until the sudden onset of pain. The pain started at 1:00am but she didn’t come in until after 7:00. Physical exam reveals peritonitis diffuse abdominal pain worse in the lower abdomen then she quickly begins complaining of pain in the right shoulder and pain with taking a deep breath. She starts hyperventilating and having panic attacks because of the shoulder and back pain and worsening abdominal pain. I did a quick point-of-care ultrasound which showed her abdomen to be full of free fluid, presumably blood. Two large bore IVs and aggressive volume resuscitation. She flat out refused straight cath for a urine sample (and rapid pregnancy test) to the point of hysteria and was actually kicking and screaming. Of course she couldn’t pee. After
some pain medicine and some serious convincing she finally allowed me to do a cath with some local gel for anesthetic. I did the cath and ran the specimen to the lab myself demanding results “yesterday.” We can get serum pregnancy tests but they take much longer. I can get a urine test in minutes—if I can get urine. So of course the urine test is positive—we’ve got a ruptured ectopic. We do not have obstetrics or gynecology at my hospital so I called the hospital 70 miles away for a transfer. 16 minutes later despite calling the stat line they get gynecology on the phone who basically refuses to take the patient because she’s unstable. She insists a general surgeon can take her to the operating room and take care of this. I call my general surgeon and he says, “I cannot operate on a ruptured ectopic but will come in and see her.” I call gynecology back letting them know I don’t want to delay her transfer and by this time I know the helicopter isn’t flying because of weather so they’re an hour and a half away by ground. “I’m just trying to do what’s in the best interest of the patient,” she says, therefore implying that I am not. General surgery arrives while I am trying to explain to gynecology that in critical access facilities sometimes we have to send unstable patients. If I have somebody with a head bleed or an aortic dissection I have to send them to a neurosurgeon or cardiothoracic surgeon. We have to send heart attacks to the cath lab, etc. We do our best to stabilize them but transferring unstable patients is something we do on a regular basis. As we’re getting into the risk benefit discussion the surgeon walked in and she is telling me, “I can walk the surgeon through the procedure if need be.” I hand the phone to him saying that gynecology wants to talk to him and step outside the office. >>
I’m just trying to do what’s in the best interest of the patient,’ she says, therefore implying that I am not.
COMMON SENSE JANUARY/FEBRUARY 2023
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