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Chicago, IL


Return Precautions: Proof of concept

Michael Macias

They say that a snapshot (picture) is worth 1000 words but in the emergency department, it may not be enough. 

A 40 y/o gentleman presented to the emergency department with acute onset of epigastric abdominal pain. He noted the pain to be burning and persistent without any alleviating or exacerbating factors. He did endorse nausea however no vomiting. He denied any alcohol use, drug use or tobacco. He had no PMHx and did not use daily NSAIDs. He had no fever and no diarrhea. His EKG was normal sinus rhythm.

His vitals were within normal limits and his exam was notable for epigastric tenderness to palpation without rebound, however patient was writhing on the bed and pain did appear out of proportion to exam. Lactic acid was sent as well as CBC/chem/LFTs/lipase which were normal. Given his exam, CT abdomen/pelvis with PO/IV contrast was ordered which returned stone cold normal. 


Throughout the patient's work up he continued to ask for dilaudid IV for his pain (maalox, pepcid, viscous lidocaine did nothing) and after having a CT scan return which was normal, there became concern for pain medication seeking behavior. After discussing with the patient that his imaging was normal and that we did not know the source of his severe pain, we attempted to stop his IV pain medications which the patient did not understand and became frustrated with. At this time we then offered him admission to observation given that he could not stay in the ED for pain control which he denied and was discharged with 3 days of Norco and a PPI. Return precautions were provided for any change or worsening of abdominal pain or new fever. 

The patient returned the next day. 

He now noted that his pain had moved to the right lower quadrant. He was afebrile with normal vitals. His exam now with focal tenderness to the right lower quadrant and labs with an elevated white blood cell count. A repeat CT scan of his abdomen revealed acute appendicitis. He went to the OR and had his appendix removed the same day. He did well post-op. 


A snapshot.

That is the amount of information we get when a patient arrives to us in our emergency department. They look this way or they look that way, and we immediately put them into a category whether it's sick or not sick, a stoic or a complainer, crazy or not crazy, a pain seeker, a drug addict...With our preconceived notions we then go on to work up the patient in a specific manner according to what we believe to be going on, through the tinted glass of our already formulated mindset about the patient's demeanor and character. It's not that we are bad people, it's the fact that we see so many patients a day that we develop mental short cuts in order to off load our cognition and make decision making easier and more algorithmic. We are then able to take complex patient histories and transform them into logical, straightforward thought processes. Unfortunately the issue with this is that we will miss things. We will give more weight to some data and less to others that does not fit within our pattern of thinking. 

With the minimal information we work with on a daily basis and the cognitive bias that is part of the battle of being an emergency physician, we always need to understand that we will miss things and we need to make sure that we discuss with our patients before they leave what they should be on the lookout should something go wrong. This is where return precautions come in and good discharge instructions. 

The fact that you are sending a patient home means that you are saying that you have ruled out all the life threatening things that could be occurring, however you need to acknowledge that you could have missed something (data is useful at this time or percentages if you are savvy to these details) or that this could be something that is occurring which is too early to pick up clinically at this time. I like to tell patient's that "here in the emergency room we only get a 'snapshot' of you and that often some things take time to develop which can be subtle or not visible initially."

You should then include the symptoms that they need to look out for which they should return to the emergency department or call there primary physician immediately for. These symptoms should be tailored to the patient's initial chief complaint and ideally include all of the possible symptoms of any life threatening illness. For example when discharging patient's with mild TBI, ACEP recommends including 6 factors: altered mental status (confusion), amnesia, headache, vomiting, neurologic deficit and seizure. 

Next time you discharge a patient, think about what could happen when they get home. Don't assume you ruled everything out, even if you think you have a diagnosis already, because guess what, you could be wrong. And when you're tired, and it's been a long shift of nothing, just remember that your last patient could have something. 


Thank you for reading.

By Michael Macias