Archives for September 7, 2006

Change of Shift 1:6

It’s up: cooltext190913551.jpg

Welcome to the latest edition of “Change of Shift: A Nursing Blog Carnival”!

Letting the Cat out of the Bag

Recently, I let the cat out of the bag.  (I looked that up on Google and found several definitions / explanations, and they agree on ‘ letting out a secret’, but cannot agree on an origin; no matter.)  The result was uncomfortable, for all of us.

So, it’s about 1AM and the place is packed, as usual.  I pull the chart of a very young female, with the chief complaint “abd. pain”.  No worries, probably a UTI.  To the room.

Patient is pleasant, cooperative (a big plus).  Mom is nice, but lets the patient give the history, which is less complicated and easier for me (bonus!).  Patient able to give chief complaint in less than 2 sentences (on a roll!).  Pain is in low pelvis, intermittent, worse sitting up, better lying down, maybe better after urination.  No fever / chills, no NVD, etc.  On the the physical exam.

Patient lies supine.  As it’s an abdominal complaint, the first place my hand goes is the upper abdomen.  It’s where I start, and where patients are comfortable with me starting (don’t just go to the the pelvis student docs, it makes patients tense up very quickly).  And, this isn’t a normal abdomen.

If you’ve handled many bellies one of the things you know instinctively is that they’re normally soft, and there aren’t any really hard or lumpy spots unless something is wrong, or you’re examining a body builder (and that hasn’t happened in my practice).

When I palpated something really hard in the upper abdomen, surprise went through my arm, and my brain wasn’t far behind.  I continued the examination of the abdomen, knew what this lumpiness meant, and said completely without thinking “…when are you due”?

The instant fear in the patient’s eyes got my attention, just as the sound of mom’s gasp reached my ears.  I felt a bit more of the  abdomen to be sure, and awkwardly excused myself with ‘ let me go get the sono machine, I’ll be right back…’.  Oh, I got to make the Big Announcement.  Great….

The sono machine preceded me into the cubicle, and a show and tell of baby parts was made to a completely unappreciative (or just stunned) audience.  About 34 weeks gestation by the machine calculations.  The now older mom was teary but in control, and the now-outed very-young mom was unhappy, but more in the loss-of-denial way than any anger or defiance.

The lower abdominal pains were contractions.  Early teen pregnancy isn’t the diagnosis I’d thought I’d make.

I felt about 2 inches tall the rest of the night, because I had let the cat out of the bag into the wild rather than facilitate the release under more controlled circumstances.  The patient and mom went to the Labor Deck to meet with the nurses there, and the social workers.

I blog this as a warning to other docs: you’re going to get surprised, eventually.  Keep the cat in the bag until everyone is ready to catch, including you.