Ate a sewing needle

[dalem11]

Advertisement - Members don't see this ad

60 y/o female trying to do some sewing and the needle slips and falls in her stomach (at least she thinks it did). No symptoms. This occurred 3 days ago. Xray'd her neck, cxr, abdomen and I see it broken in 2 in the RUQ, past the pylorus.

Now there is a lot of controversy regarding the management of these. Very low percentage perforate and in adults I would think they would understand whn it starts hurting and when to go back to the ER. In children it is different.

A couple of quesions:
1. Would you send the lady home with surgery/gi follow up for repeat abdominal exams and xrays?
2. Admit her for surgery and get a ex lap done to find the needle to take it out
3. Call GI who wouldnt even be able to find the needle since it is too far past the pylorus but could follow her up.
4. Or do something else?

I am interested to see what people think and then I will tell you what I did.

Thansk

 

[leorl]

I'd probably at least get GI and gen surg consults simultaneously. Length-wise it shouldn't be a problem and it's already been 3 days, but it is a very sharp object... ultimately they'd probably say conservative management and send her home, but who knows? In the event that neither services are instantly available in your hospital, I'd call them and arrange for urgent followup appt as well as PMD for close followup.

 

[txterp98]

3 days later....asymptomatic. Sounds from this, there's no pain or tenderness. Plus, there's no free air on X-ray (which confirms the history/physical). And the needle is past the pylorus.

You're exactly right...we're past GI's ability to help.

I'd call surgery for follow-up in 2-3 days for a repeat X-ray/consultation. And like you said...this is an adult who can perceive pain and can follow ER precautions.

GI consult....no. General surgery consult in the ER....sounds like overkill. Sure, it's great to help "buff the chart" and CYA. But you know, we're board certified EM docs. This is the value we bring to the department. Anybody can see a patient and then consult services. That's what adds to the negative stigma of EM physicians and likely rightfully so for those physicians. Get a consult on a clear case of peritonitis or for a questionable exam where you truly need another opinion. But everything's normal? No ER consultation needed.

If I'm not mistaken, now that the foreign body is past the pylorus, the next possible hold-up point will be the ileocecal valve. Can't remember where I heard or read it, but I believe 3 days at the ileocecal valve without passage is a surgical indication.

So to sum it up: return for worsening of condition. Otherwise, follow-up in 2-3 days at a general surgeon's office for repeat X-ray and exam.

 

[deleted109597]

Yep. Treat it like a kid who swallowed a marble. If it isn't in the stomach, they get repeat xrays in a few days. No need to strain the stool. If it gets stuck, someone has to go get it.

 

[Groove]

GI consult. Don't know about you guys but the pylorus many times doesn't exactly reach out and slap me from the XR. Our GI guys can get to the first 2 parts of duodenum for retrieval. If it's been 3 days, and it's still there... it's stuck. You really want that thing migrating around near the vasculature feeding the gut? What if it migrated through and perf'd one of the arteries or finally lodged itself in the pancreas. Next presenting sx might be pain assoc with positive FAST. Call me gun shy, but I can think of damn near anything bad that can happen from the most benign presentations. If it's broken, who's to say the broken end isn't malformed with a dentation or tooth hook on the end where it broke...the back ass end of it could grab and pull as it migrated through.

I'd want some chart buffing by a consult or two. GI vs Surg or both.

At the very least, a GI consult, because like I said... ours can retrieve from first 2 parts. I mean....forget standard of care... I'd want the damn thing out if at all possible, wouldn't you guys?

Is anybody going to retrieve it or perform surgery? Prob not, but I don't think that's my decision to make alone.

 

[Apollyon]

GI consult. Don't know about you guys but the pylorus many times doesn't exactly reach out and slap me from the XR. Our GI guys can get to the first 2 parts of duodenum for retrieval. If it's been 3 days, and it's still there... it's stuck. You really want that thing migrating around near the vasculature feeding the gut? What if it migrated through and perf'd one of the arteries or finally lodged itself in the pancreas. Next presenting sx might be pain assoc with positive FAST. Call me gun shy, but I can think of damn near anything bad that can happen from the most benign presentations. If it's broken, who's to say the broken end isn't malformed with a dentation or tooth hook on the end where it broke...the back ass end of it could grab and pull as it migrated through.

I'd want some chart buffing by a consult or two. GI vs Surg or both.

At the very least, a GI consult, because like I said... ours can retrieve from first 2 parts. I mean....forget standard of care... I'd want the damn thing out if at all possible, wouldn't you guys?

Is anybody going to retrieve it or perform surgery? Prob not, but I don't think that's my decision to make alone.

Dude...you're a resident, I'm an attending, and we're on the same page. Exactly - spread the love. Exactly - would YOU let your mother cruise around with a broken needle in the belly? Seriously?

Some folks sound REALLY cowboy-ish here on this topic. Call ME gun-shy, but I ain't tellin' this lady to "go with God, and come back if your pain is worse" without discussing this with someone (or a few people).

 

[deleted109597]

Apollyon, most of us are coming at it pragmatically. I call GI, they tell me that it isn't their problem without consulting. I call surgery, they laugh at me and I get a letter from the CMO about inappropriate consults. I call medicine to obs, and they ask me what GI/Surgery say.

Yes, in a perfect world, they could be watched my thoughtful nurses and nothing bad happens. However, just like people who have paroxysmal SVT, can we just watch them all the time just in case something bad happens?
There is literature support of the watch and wait pathway.

 

[txterp98]

Apollyon, I agree with your words "without discussing this with someone." Out of curiousity, are you happy with the phone consultation/referral or do you want an actual consultation note on the chart?

I suppose I could've been slightly clearer on my first post. When I say follow-up with surgery in 2-3 days, I would've discussed the case with the surgeon via phone to help arrange the follow-up visit.

 

[Apollyon]

Apollyon, most of us are coming at it pragmatically. I call GI, they tell me that it isn't their problem without consulting. I call surgery, they laugh at me and I get a letter from the CMO about inappropriate consults. I call medicine to obs, and they ask me what GI/Surgery say.

Yes, in a perfect world, they could be watched my thoughtful nurses and nothing bad happens. However, just like people who have paroxysmal SVT, can we just watch them all the time just in case something bad happens?
There is literature support of the watch and wait pathway.

If GenSx reports your for an inappropriate consult for a metallic foreign body, then you need to go work somewhere else. I am completely honest when I say that, because, if your general surgeons are saying that, then they're screwing you - royally. And, irrespective of literature support, how much heat does an anecdotal report bring in court? (As I hope you don't yet know, a lot - the literature goes out the window when the scumbag lawyers can paint a gloriously colorful picture to the jury.)

Apollyon, I agree with your words "without discussing this with someone." Out of curiousity, are you happy with the phone consultation/referral or do you want an actual consultation note on the chart?

I suppose I could've been slightly clearer on my first post. When I say follow-up with surgery in 2-3 days, I would've discussed the case with the surgeon via phone to help arrange the follow-up visit.

I don't know what is the beef about a "consult" - I would talk with GenSx on the phone, tell them what is up, discuss it cleanly, and document that. At the same time, in my community practice, with mostly Chinese surgeons (one Japanese guy), I have no problem getting them to come in, as much as they bitch and complain (same with ENT - two Chinese guys, who will gripe continuously, but they come in) - I don't even have to beg them. As far as GenSx, maybe it's because they all do transplant, too, that they're used to the all-hours thing.

Ironically, this recalls a case when I was a student in Brooklyn. There was a drug mule that didn't pass a condom, and she was observed for days in the hospital - and the one Chinese surgeon ended up doing an open lap and recovering it. Then again, this was 2001.

 

[deleted109597]

If GenSx reports your for an inappropriate consult for a metallic foreign body, then you need to go work somewhere else. I am completely honest when I say that, because, if your general surgeons are saying that, then they're screwing you - royally. And, irrespective of literature support, how much heat does an anecdotal report bring in court? (As I hope you don't yet know, a lot - the literature goes out the window when the scumbag lawyers can paint a gloriously colorful picture to the jury.)

They can paint a picture about me giving a tetanus shot gave their kid autism as well. It's up to us to determine what the patient needs. At this point, they don't need a surgeon. He's not going to operate on her unless she needs it. My surgeons aren't in house at night. Sure, during the day I may call one to get followup, but it isn't the same after 5pm.
If it were my mother (or wife), I truthfully wouldn't have a problem with watchful waiting, as long as they were comfortable with it, since it isn't my decision and all. I can't imagine that a surgical extraction of this item would be laparoscopic either before or after perf, so either way gets a zipper up the front. If GI could get it out, then I'd be for that, but I work at a place that doesn't have GI coverage every day (or uro, or plastics).
So once again I guess I just have to say I'm being realistic.


As far as the complaint, yeah, some of the surgeons are bitter here. In this instance, I agree with them. This patient doesn't need a surgeon at this time, so calling them just interrupts their sleep. And no, I haven't gotten a complaint personally, but I have gotten emails from the director about other people doing it. Honestly, it's not that negative a place, but there a few things that annoy us.