“Let’s move it, guys, the bus is unloading!” You cringe as you hear the jaded tone in your nurse’s voice. Your department has been especially busy this past month with high-acuity patients, and your hospital is slowly and surely running out of space and resources. Couple all of this with crabby consultants and patients tired of the long wait times, and it is no surprise that your staff and colleagues are getting a little burned out.

Your resident approaches you with the next patient to discuss and you soon find out that the nurses aren’t the only ones who have been bitten by the “burn-out bug”. “This guy is back again…” you can almost feel the exasperation in his voice. “He was just here last week for the same abdominal pain and he’s back again today asking for more pain medications.”

You listen patiently as your resident summarizes his case. The patient is a 45 year-old male who suffered a gunshot wound to his abdomen a few years back. He has had multiple visits to your ED subsequently for chronic abdominal pain and requests for prescriptions for narcotics. He has normal vital signs today and is hunched over and groaning in bed. He moans in pain everywhere you touch him, and he says yes to everything on his review of systems. He continues to beg for IV pain medications and is wondering if he can get IV Phenergan for the nausea and IV Benadryl for the itching he always gets with IV narcotics. The nurses have informed your impressionable young resident that “this is how he always looks” and that “all he needs is some IV Dilaudid and he’ll just get up and walk out soon afterwards”.

You ask your resident, “What’s your plan?” to which he replies, “I just want to get him outta here.” You are surprised by his cynicism so early on in his training. It is only the 2nd month of his second year in EM residency and he’s already feeling jaded. Not good. Not good at all. “Let’s think about what we could be missing here…” you reply. “What’s on your differential for this young man?” Your resident rattles off a list straight out of Tintinalli’s: pancreatitis, appendicitis, diverticulitis, cholecystitis, choledolcholithiasis, nephrolithiasis, AAA, mesenteric ischemia, small bowel obstruction, ileus, diverticulitis, perforated ulcer, gastritis, inferior MI, lower lobe pneumonia, toxin exposure, etc.

Just for fun, you have your resident wheel in the ultrasound machine into the patient’s room with you as you go in to try to tease out a few more details. As your resident scans through the patient’s right upper quadrant, you discover the patient has no history of gallbladder issues, and the pain is not associated with food or alcohol consumption. Your resident performs a scan of the patient’s kidneys, and you uncover that the patient has no dysuria, hematuria, penile discharge, or flank pain. Moving onto the abdomen, you start questioning the patient about his bowel habits and appetite. Your train of thought is interrupted when you see the ultrasound images your resident gets of the patient’s abdomen (Image 1).

What do you see on ultrasound? Will this patient do well with just IV Dilaudid and an outpatient narcotic prescription this time?

What does the ultrasound show?


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