BOSTON – For veteran emergency physician Joseph Danna, MD, FACEP, Monday’s ACEP15 session, “The High-Risk Abdomen: Common Complaints and Crashing Patients,” was one of the more unnerving. That’s because it delved into what presenter Diane Birnbaumer, MD, FACEP, calls “this black box of a belly.”

Abdominal complaints are “one of the ones that are most unsettling because the list of possibilities is endless, if you will,” said Dr. Danna, chief executive of Emergency Care & Health Organization, Limited, in Kanakee, Illinois. “For me, the way I approach these patients is I’m very cautious, sometimes some might think overly cautious. I like to watch them for an extended period of time to see if they are evolving or not.”

Giving high-risk abdominal patients time is one of Dr. Birnbaumer’s take-home points for emergency physicians. In her rapid-fire presentation, she suggested doctors:

• Order the tests they wanted to order if it’s going to keep them up at night;
• Be timely in ordering tests and making a diagnosis. Sequential ordering in high-risk patients may not be as efficient as parallel ordering;
• Use SPIT as a pneumonic diagnostic tool. It stands for “serious, probable, interesting” and is a way to pay attention to presentations that might not normally be front of mind;
• Avoid premature discharge, potentially by using observation status;
• Make their documentation clear and complete to protect themselves medically and medicolegally.

Ordering the necessary tests—and doing it timely—is particularly critical for high-risk patients, said Dr. Birnbaumer, emeritus professor of medicine at David Geffen School of Medicine at UCLA and senior clinical educator in the department of emergency medicine at Harbor-UCLA Medical Center in Torrance, California.

“When it comes to belly pain, please do not hesitate getting the ultrasound if you think it’s an appy in a kid. Getting a CT scan if you’re worried about diverticular disease in somebody older. Just do it,” she says. “For heaven’s sake, just do it. It is how we get into this black box of a belly and figure out what’s wrong. Don’t do it with everybody, but, boy, please if you need it, go ahead and order the test.”

Johnnie Ford, MD, FACEP, an emergency physician in Northern Virginia, will use the SPIT tool when he gets home later this week. He likes the idea that it keeps him “mentally flexible.”

“The high risk patients, they’re going to have really weird findings,” Dr. Ford said. “These are the (warning) signs and people that end up in court, that end up in lawsuits, that end up coming to your hospital administrator. They’re not the norm. So talks like this help you hone in on those kinds of folks and make the right decision.