"Acute appendicitis and ED experience"

I am a Clinical Nurse with 20yrs adult, ED experience. However my experience with paediatrics is minimal. I know all the staff work tirelessly to provide the best care to all the patients that present. Thank you.

My child attended PCH ED mid-late 2020 at about midday. I bought them in as I suspected they were suffering from an acute appendicitis. We saw the triage nurse and explained the signs and symptoms they were experiencing, which was RLQ abdominal pain, nausea and vomiting since 2200 the night before. They had some simple analgesia prior to going to bed. My child is stoic with good pain tolerance.

(In 2019 they suffered a displaced fracture of the first metacarpal of their left hand which required k-wire fixation. Despite obvious deformity, they said the pain was not too bad as long as they didn’t move it. They were administered intranasal fentanyl almost immediately. They were seen and discharged within 3hours, to return the next day for surgery. They also sustained a buckle fracture of their left wrist later the same year.)

My child informed me their abdominal pain was a 8/10 and they looked miserable. Prior to attending ED, they were in tears and unable to walk/stand because of the pain. I had not administered any analgesia prior to attending ED due to nausea and vomiting they had 30mins prior to seeking assessment/treatment, which I stated to the triage nurse. The triage nurse asked if I had anything else I thought might be relevant, I should have told them about my child's pain score and their pain tolerance. However, I was functioning on about 2.5hrs sleep as I had just finished a 12hr night shift at 0730 that morning. 

After waiting two hours in ED, my child was exhausted and was trying to sleep, they didn’t look too uncomfortable but was still reporting to me they had 6/10 pain. I decided to inquire as to how much longer the wait was, I was starting to doubt myself and was wondering if I was overreacting to a viral, gastro bug or food poisoning.

After a 3 hr wait, we were taken in to be seen, it was at this point I saw that my child’s triage paperwork and saw they had been allocated an ATS 4. This concerned me greatly as I had been taught to triage any patient with symptoms of abdominal pain and possible appendicitis as an ATS 3. During the three hour wait to be seen my child was not offered any analgesia or antiemetics.

My child was quite dehydrated and it took 10 attempts to site an IV which was finally achieved by a senior ICU Reg that night. By this point, my child had received oral analgesia and had been confirmed to have a necrotic appendix.

My child remained fast as staff were trying to get them to theatres that night. However, about midnight we were told that surgery would happen the next morning.

My child woke at 6 am complaining of pain, they had received their limit of simple analgesia and they were administered oral oxycodone, their pain improved and they managed to FaceTime their grandma for a short call.

However one and a half hours later, their pain hit an all-time high. My stoic child was screaming and crying in pain. I knew their appendix had just ruptured and my heart was breaking because there was nothing I could do to ease their pain. After 30mins my child was given some Ibuprofen and after another 30mins of screaming and crying, they must have exhausted themselves and finally felt some relief and dozed lightly.

They were finally admitted for surgery at mid-morning where their ruptured, necrotic appendix was removed and their abdominal cavity was irrigated as they were in the early stages of peritonitis. The surgeons stated my child was lucky that we waited to get surgery as it was complicated due to the rupture and leaking bowel content and we had an experienced senior surgeon perform the surgery.

However, I still wonder if my child had been allocated an ATS 3, would they have been seen sooner, received surgery sooner and would have had less complications if their surgery could have been attended to on the day we presented rather than 24 hrs after?

My child has no lasting complications, however, their needle phobia is 100x worse. They can’t even tolerate me talking to their older brother about their immunisations that are due this year without them suffering extreme anxiety.

I know what working in ED is like and the pressures of a busy department. I know that there is a lot of responsibility and accountability for the triage nurse. I just feel that I would not have allocated an ATS of 4 to an adult who presents with the signs and symptoms that my child had and feel there is a learning opportunity for the triage nurse.

I’m grateful for the care my child received and would like to thank all the staff, from the nurses, doctors, surgeons, cleaners, clerical staff, PCAs for the work they do.