A case to illustrate the increasing inability of physicians to understand or diagnose hernias: A true story (maybe some of you enterprising members can write a screenplay from this--Hernia! The Movie):
A 78 yo female showed up in a nameless ER 3/25 complaining of headache, "chest pain" and nausea and vomiting, altho the lady herself later claimed she never had headache, only increasing weakness, nausea and vomiting. The ER note, and subsequent admission H&P to family practice, documented a 5x5 cm right inguinal "mass" or "tender adenopathy", which patient claimed had been present for the past 2 weeks and was becoming increasingly tender. On P.E. the abdomen was noted to be "tender" and distended with diminished bowel sounds--admission diagnosis--"R/O MI". Over the next TWO DAYS they proceeded to get a few EKG's and a few runs of cardiac enzymes (all normal), not making much of her continued vomiting (treated with the magic pill--er, I mean phenergan) or her failure to pass any flatus or bowel movement, and an absence of any urine output for two shifts (16 hours). 48 hours after admission, the first attending Family Practice note appears on the chart, after morning rounds on 3/27 at 10am, noting again a tender R inguinal mass, abdominal distention and "rebound" and absent bowel sounds, and diminished mental status--his assessment that surgery should be consulted(it is clear he also did not have any understanding what was happening, just that the patient looked sick and it appeared to be from her belly) was not actually done until 2pm, because of course a CT of the head and flat and uprite abdominal X-rays first had to be gotten. Our second year junior surgery resident then saw the patient, within one minute called me and said she had an incarcerated, probably strangulated inguinal hernia (i.e. this was not a difficult call), X-rays showed dilated smal bowel loops with air-fluid levels and no air in the colon, abdomen had rigid peritonitis, CT head was normal (really?), and there was heat and erythema over the swollen tender right groin. No fever, WBC that am was 2.3K. A foley catheter was placed and it produced a little fogging with a drop or two of brownish jelly(I.e. very concentrated and scant urine)
The patient was lethargic but nonetheless had enough together to categorically refuse surgery--family was called and her next of kin daughter also refused surgery for her over the phone, but were on their way in. Meanwhile we suggested starting another couple IV's to supplement her indwelling 20g catheter with KVO fluids, and started pouring fluids into her. At 5pm, she dropped her blood pressure to 70/40, pulse 150, although urine had picked up--at least by now had turned back to liquid consistency. Antibiotics were empirically started in anticipation fo family consenting to surgery. But when daughter arrived, she still refused surgery, and mother by now was unresponsive--bloood gas showed pH 7.06, pCO2 70, pO2 100 We brought her up to the ICU, placed a Swan-Ganz catheter (sorry surgeon, but do believe it would help here in assessing endpoints for resuscitation) and intubated her.
As I predicted when patient initially refused surgery--it's uncanny how predictable these cases always are--the daughter finally consented at 11pm when patient was starting to see St. Peter (he guards the heavenly gates for us Catholics, surgeon), and we had her in recovery room by 12:30am. Laparotomy showed liters of watery brown fluid without odor and a necrotic loop of mid-jejunum with both open ends waving in the breeze, obviously having fallen out of the very tight hernia--we did a quick stapled anastomosis--the proximal limb wasn't very distended, as obviously it had decompressed its contents over the last few hours--and closed the hernia sac with a purse string from inside the abdomen. There was no solid debris and no exudate or walling off of the spillage, suggesting to us it had been around for only a few hours. No other pathology found. We sucked out all fluid, washed the remainder with only about a liter of saline, closed the abdomen, left the skin open, then I opened up the groin to expose the canal because of the obvious contamination that must have happened in the inguinal tissues--no obvious evidnec of contamination or infection there, and we packed that open too. Over the next 2 days, she was quite unstable with a clincal picture of SIRS--no fever, WBC only reached 10K, but sequestered large volumes(we were as much as 12 liters ahead on day 2), and ended up on hi doses of dopamine and epinephrine to maintrain pressures of 70-80mmHg. She became oliguric on day 2 and we were ready for renal shutdown, but renal function never did deteriorate, and on day 3 she began a spontaneous diuresis, lung compliance dramatically improved, and today on 15ug/kg dopamine and off dopamine and all maintenance fluids has a cardiac index of 4.0, PCWP 12, BUN 18, Creat 0.9, pH 7.34, pCO2 43, pO2 on 40% FIO2 100, and urine output 100-150cc/hr. She looks great!
Now--besides the obvious issue of delayed diagnosis--for those with comments, address how you would handle her antibiotics.