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CE ARTICLE Meet the Speakers! is vague and may not lead you directly to the pathology, unlike the cases above. It is your responsibility to remember that, even without a serious differential diagnosis, hemodynamic instability may occur at any time and regular reevalua- tion during transport is important. These patients should receive a thorough phys- ical exam, checking the genital area for gross bleeding. Internal pelvic exams are not performed by EMS providers. Any time a patient presents with signs of hemody- namic instability, including tachycardia, signs of dehydration or falling blood pressure, administer normal saline through at least one IV. The abdominal compartment can hold a lot of fluid, and significant internal bleeding can occur before physical symptoms develop. Keep all patients with abdominal pain NPO, as they might need emergent surgery, and because food releases gastric and pancreatic contents and shunts vital blood flow from other organs to the gut. Monitor vital signs periodically and use the Trendelenburg position if blood Come to the EMS World Booth #3602 at the 2011 EMS World Expo in Las Vegas, NV, to meet all your favorite EMS World Magazine and EMSWorld. com contributors, including CE authors Kevin Collopy and Scott Snyder. Kevin and Scott will be at the booth from 1–2 p.m., Thursday, September 1. For more information, visit www.emsworldexpo.com. can be done in managing this patient. In the case of pelvic pathology, the OB/GYN on call will normally be activated to do a thorough physical exam and a vaginal ultrasound. CT/MRI or US may be used to further narrow down the diagnosis, along with blood tests to measure pancreatic enzyme activity, liver function, and markers of inflammation and infection. A surgeon or internal medicine staff may be called in for definitive management. Conclusion Although abdominal pain in the potentially pregnant female can seem quite complex, once broken down to simple steps, management is quite simple. Remembering the ABCs and using a systematic approach on each patient can help simplify the emergency. “Don’t go looking for a zebra when a horse is right in front of you.” There are two ways to take the CE test that accompanies this article and receive 1.5 hours of CE credit accredited by CECBEMS: 1. Go online to EMSWorld.com/ cetest to download a PDF of the test. The PDF has instructions for completing the test. 2. Or go online to www. rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@ EMSWorld.com. pressure dictates; otherwise, place the patient in a position of comfort. IV pain medication can be started to provide patient comfort, but it is best to contact medical control or the receiving facility for recommendations. Transition of care should convey the emergent status of the patient using pertinent history, trended vital signs and physical exam findings. If there is something you feel the receiving staff should be told, make it known no matter how busy they are. You sometimes have information from the field that is not available to the emergency department. ED management consists of reevalu- ation and narrowing down the differen- tial diagnoses. After initial stabilization, a complete history and physical, one of the first tests run will be a pregnancy test, as it can affect the differential diagnosis, as well as which drugs or imaging studies 64 JULY 2011 | EMSWORLD.com You should feel a certain sense of relief that your job is to stabilize and transport to the appropriate facility as quickly and comfortably as possible, leaving some of the more difficult diagnoses to the hospital team. Try to notify the receiving facility as early as possible so they can activate the necessary teams, even if they are not as receptive as you would like. This can make a large difference in ED staff preparedness and improve patient care. With any emergency, EMTs must act as the liaison between patient, family and hospital staff for the most effective management of even the most complex patients. REFERENCES 1. Bengiamin R, Budhram G, King K, Wightman J. Chapter 21: Abdominal Pain. In: Marx J, ed. MD Consult: Marx: Rosen’s Emergency Medicine, Vol 2010. Mosby, 2009. 2. Chapter 145: Infl ammatory and anatomic diseases of the intestine, peritoneum, mesentery and omentum. from Goldman: Cecil Medicine, on MD Consult. www. mdconsult.com.libproxy.tulane.edu:2048/das/book/ body/225578276-5/1079522335/1492/553.html#4- u1.0-B978-1-4160-2805-5..50150-6--cesec1_6312. 3. Curtis KM et al. Visits to emergency departments for gynecologic disorders in the United States, 1992–1994. Obstet Gynecol 91:1007, 1998. 4. Colucciello SA, Lukens TW, Morgan DL. Abdominal pain: An evidence-based approach. Emerg Med Pract 1:2, 1999. 5. Core T, Hayes K. Acute abdominal pain: A systematic approach to adult assessment. Nursing Critical Care, 2010. http://journals.lww.com/nursingcriticalcare/ Abstract/2008/05000/Acute_abdominal_pain__A_ systematic_approach_to.7.aspx. 6. Thomas SH, Silen W, Cheema F, et al. Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: A prospective, randomized trial. J Am Coll Surg 196(1):18–31, 2003. 7. Dahlberg D, Lee C, Fenion T, Willoughby D. Differential diagnosis of abdominal pain in women of childbearing age: Appendicitis or pelvic infl ammatory disease? Adv Nurse Pract 12(1):40, 2004. 8. Morishita K, Gushimiyagi M, Hashiguchi M, et al. Clinical prediction rule to distinguish pelvic infl ammatory disease from acute appendicitis in women of childbearing age. Am J Emerg Med 25(2):152–157, 2007. 9. Beigi RH, Wiesenfeld H. Pelvic infl ammatory disease: New diagnostic criteria and treatment. Obstet Gynecol Clin North Am 30:777, 2003. 10. Centers for Disease Control and Prevention: 2006 guidelines for treatment of sexually transmitted disease. MMWR 55:11, 2006. 11. Gupta K, Wu B. Acute pancreatitis Ann Intern Med 153(9):ITC51, 2010. Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also a fl ight paramedic for Ministry Spirit Medical Transportation in central Wisconsin and a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org. Jake Kleinman, MD, EMT-D, is a pediatric resident at Tulane University Hospital in New Orleans. He holds an MD degree from Tulane University School of Medicine and a BA from Colgate University. He got his start in medicine as an EMT-B riding for both Chappaqua Volunteer Ambulance Corps and Southern Madison County Ambulance Corps (SOMAC) in Hamilton, NY. Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California San Francisco and a former New York City paramedic for 10 years. Contact him at sean. kivlehan@gmail.com. Scott R. Snyder, BS, NREMT-P, is the EMS education manager for the San Francisco Paramedic Associa- tion in San Francisco, CA, where he is responsible for the original and continuing education of EMTs and paramedics. Scott has worked on numerous publications as an editor, contributing author and author, and enjoys presenting on both clinical and EMS educator topics. Contact him at scottrsnyder@ me.com. To access additional continuing education articles, visit www.EMSWorld.com/cetest.