Appendicitis – An EMS Case Review

It’s a dreary, grey late fall day outside and your partner is driving your rig back from the hospital after clearing from a call. You’re feeling very comfortable in the passenger seat of your ambulance as the radio’s playing some annoying pop-drivel by whatever flavor of boy band is popular this month. You’re tired from working the day before and having to pick up overtime today and seem to be getting sleepier by the minute. It may be cold outside but the heater in your ambulance is working quite well and the warm, comfortable seat is lulling you to sleep. It’s a perfect time to doze off for a little snooze and your eyes just seem to close on their own…

And with that, the secret alarm goes off in dispatch to alert them to the fact that an EMS provider has dozed off and they subsequently set off your tones to alert you to a call. The dispatcher’s voice harshly cuts into your mid-afternoon nap by sending you to the local community college for a 23yo female patient experiencing an onset of abdominal pain. Your partner flips on the lights and sirens as you sleepily acknowledge the call and mark your unit en route. So much for nap time.

You arrive shortly thereafter and pull up to the entrance by the college health center behind the security vehicle. The security officer is holding the door open for you as you grab your equipment and wheel in the cot. He leads you to the health center office while attempting to engage you in small-talk. Through the fog of your still-tired brain you try to politely converse along with him but it doesn’t work so well and you think that you may have agreed to take him on a ride-along. Oh well.

Your patient is a 23yo female who is sitting on the exam table in the health center. She is slightly bending forward and is holding the right lower quadrant of her abdomen. There was no nurse on-duty today and the administrative assistant called 911 after the student came in complaining of the abdominal pain.

“Howdy!” you say to the patient, professionally. “My name’s Joe and I’m from the ambulance. What seems to be the problem today?” you ask.

“My stomach hurts like, really bad.” She answers, wincing as she talks. She seems to be in a significant amount of pain and grimaces as you get near her. She doesn’t seem to want you to touch her abdomen and seems scared that you’re going to. You continue to ask her questions while your partner gets out a blood pressure cuff and starts to take her vital signs. You check her radial pulse and find out that her pulse is elevated, about 118bpm, her respiratory rate is about 20 and shallow, and her skin is warmer than normal and slightly moist. Your partner reports a blood pressure of 108/88.

“What’s been going on today? Can you point to where your stomach hurts?” you ask her in succession. She tells you that she’s been experiencing abdominal pain that has been steadily worsening over the last three days and that it’s suddenly gotten much, much worse over the last hour. She rates it at an “8” out of 10. She says that it doesn’t quite hurt as much as did the birth of her child, but that it’s “getting to be right up there.” She indicates with her hand that the pain started in the middle of her abdomen around her umbilicus, but points to the area between her right iliac crest (hip bone) and her navel and tells you that this is where it hurts the most since the pain has gotten worse. She denies diarrhea, vaginal bleeding, and trauma but tells you that she vomited this morning and is feeling nauseated. She doesn’t remember when her last oral intake was because she “just hasn’t been hungry” since this began.  She also complains of chills and her skin temperature suggests she has a fever. You confirm it with the oral thermometer that’s handily on the wall of the health center and find out that her temperature is 101.3. She tells you that it hurts to cough and that it hurts more when she moves.

You lie her down on the table and examine her. Her lung sounds are clear and her abdominal sounds are hypoactive. Her abdomen is rigid and tender in all 4 quadrants, especially over the RLQ which she guards with her hands. She winces noticeably when you take your hands off of her abdomen and says that the pain seemed to be much worse when you let the pressure off.

You and your partner move her to your cot and sit her in semi-fowlers position. You bundle her up tight with blankets while your partner and the security officer grab up your gear to carry it to the rig. The motion of moving her to the cot seems to have made the patient’s pain worse and she is obviously struggling against it. As you load her in the ambulance, you try to think about what this could be. You quickly remember that “All abdominal pain in a female of child-bearing age is an ectopic pregnancy until proven otherwise” and ask the patient when her last menstrual period was. She tells you that it ended last week, that it was normal, and denies any activities possibly leading to pregnancy in the last four months with normal menses throughout. You have a low index of suspicion for an ectopic pregnancy in this case, but are still concerned that the patient is at serious risk. Your partner turns to you and asks “So what do you think this is?”

Acute abdominal pain is a common cause for EMS calls as well as for Emergency Department and Urgent Care visits. Abdominal pain can be frustrating for EMS providers as there are a great number of conditions where the generic chief complaint of “abdominal pain” may be stated. While a complete understanding of all potential causes of abdominal pain requires extensive study and is well beyond the scope of this article, this patient is presenting with the signs and symptoms of a common and serious acute complaint. This patient complains of an onset of diffuse abdominal pain with anorexia (reduced appetite), nausea, and fever over a three day period. She stated that the pain became worse with a relatively rapid onset of right lower quadrant pain between the right iliac crest and the navel (McBurney’s Point), rebound tenderness (increase of pain when pressure is released from the abdomen after palpation), and increased pain to coughing.

The Appendix, or the “Vermiform Appendix” as it is properly known is a small organ located between the junction of the large and small intestines at the level of the cecum. It can be described as a “worm like” dead-ended tube averaging 11cm in length but ranging anywhere from 2-20cm and usually being around 7-8mm in diameter. For a very long time, the appendix has been through to be a “vestigial” organ, in that there seemed to be no obvious function for it in the body. Therefore it was assumed to have been a remnant of an organ lost to evolution. Recently there has been information suggestive of it having a role in maintaining proper levels of intestinal flora following severe diarrhea however there seems to be no obvious affect in individuals who have had it removed. “Appendicitis” or as it’s also known “epityphlitis” is an inflammation of the appendix.  In otherwise healthy individuals, the opening to the appendix can become blocked and the appendix can become inflamed and filled with excess mucous causing a build-up of pressure. The pressure caused by the trapped mucous compresses the blood vessels in the appendix which eventually causes the appendix to become ischemic, then necrotic and infected. Eventually this infection spreads to the outside of the appendix which can then cause the infection to spread to the peritoneum. In late or severe cases, the necrotic walls of the appendix can rupture or “perforate” and spread infection throughout the cavity causing an abscess or possibly sepsis.

The signs and symptoms of appendicitis start with pain first, nausea and vomiting next, and fever last. Anorexia, nausea and vomiting, and diffuse abdominal pain that is hard for the patient to localize are good potential indicators. Since the appendix is innervated at around the level of T-10 into the spinal cord, the pain starts generally in the umbilical region. As the condition progresses and the peritoneum becomes more inflamed the pain will localize to the Right lower quadrant, especially notable over “McBurney’s Point.” The pain may increase with coughing.  Peritonitis, or the inflammation of the peritoneum caused by the spreading infection will cause rebound tenderness upon palpation, notable by the abdomen hurting more when pressure is released than it did when pressure was applied. In some cases, appendicitis can cause a bowel obstruction as the intestine becomes inflamed to the point where fluids cannot pass or the patient may become septic.

Causes of appendicitis include a blockage of the lumen (opening) leading to the appendix from the cecum. This can be caused by trauma, intestinal worms, and/or lymphadenitis. However, most commonly the condition is caused by “Fecaliths,” or small, calcified pellets of bowel that form in the intestine. In some rare cases, appendicitis may clear on its own but most commonly the only option is surgery to remove the infected appendix which can be done using a few different procedures. Appendicitis is diagnosed using a proper physical examination, ultrasound, CT scanning, and sometimes abdominal x-ray films. Blood and urine testing can also be valuable. Field treatment includes keeping the patient still, keeping them hemodynamically stable using IV fluids or vasopressors in the case of septic shock, and treatment of pain using narcotics. In older times, general surgeons recommended against giving pain medications to patients with appendicitis in the fear that the medication would decrease their diagnostic sensitivity upon a physical exam. This has since been proven to be not true and patients receiving timely and proper pain control have been shown to have better outcomes overall following removal of the appendix.

Keep a high index of suspicion for your abdominal pain patients and assess them well, there’s a lot that can go wrong down there and EMS oftentimes may be the first people to catch it.

  • Great case review. I’ll add that providers should be suspicious of responding to abdominal pain that has ‘disappeared’ prior to EMS arrival. When the appendix ruptures, the pain can decrease suddenly and dramatically, to the point where the patient feels that perhaps everything is OK. Of course, as you point out, nothing could be further from the truth–a ruptured appendix is a surgical emergency. If the history described suggests appendicitis, I would strongly encourage the patient to go to the hospital for evaluation and imaging. 

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