EM Forum Case #123 "Transfer Mistake-Not"
by Charlene Babcock Irvin, MD, FACEP  

A 52 y/o male presents with a one day history of abdominal pain, nausea and vomiting. He thought he had food poisoning, but now is feeling even worse and is worried something more serious is going on. Pain is colicky, peri-umbilical, no change with urination or BM, slightly better with vomiting.

ROS: No fevers, chest pain, shortness of breath, melena, bright red blood per rectum, urinary complaints, rashes, or neurologic symptoms. No recent travel. No one else is sick at home. He did not eat anything unusual (fried chicken that was 2 days old was eaten yesterday night, and he thought that’s what was causing his food poisoning symptoms). Last BM this A.M., normal. Vomit is green, no black or blood noted.
PMH: No medical problems. No medications. Past surgical history: Appy as a child.
SH: Smoker, social alcohol drinker.
PE: 52 y/o, comfortable on the gurney.
BP: 145/85, HR=98, RR=20, Temp: 98F, Sat 96% RA
HEENT: Unremarkable
HEART: Unremarkable
LUNGS: = BS, no rales
ABD: Obese, soft, tender diffusely, voluntary guarding to deep palpation. No AAA palpated. Bowel sounds hyperactive. Rectal Brown Stool, trace guiac positive
Urologic: Descended Testes, No hernia
EXT: Unremarkable
Neurologic: Unremarkable.
WBC: 16K, HBG =15, Glucose = 120, BUN=27, Cr. = 1.3 CO2=18, Liver tests normal, Amylase 80 (Normal <60), UA Pending, EKG unremarkable.
CXR: Unremarkable.
Acute Abdominal Series is shown below.

Nurse notifies you that the blood pressure just dropped to 88, and the patient is feeling worse.

Questions:

1. What are your orders? And what does the patient have?

2. In the US, what is the most common cause of this problem?

3. Surgical consult requests a CT. CT returns with the expected diagnosis. Surgery returns to admit the patient, but then you are notified the patient needs to be transferred because of insurance reasons. The senior surgical resident notes he is stable for transport (Blood pressure 105, HR=110), and asks you to please transport him. What do you do? Transfer?

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