Patient Care

Young Athlete’s Abdominal Pain Indicative of More

Issue 2 and Volume 39.

Walking into the college locker room, you and your partner see Jeff sitting on a bench. He appears to have just showered, but he looks distressed; he’s doubled over, rocking back and forth. His rugby coach explains Jeff began complaining of abdominal pain after practice and it increased to the point he decided to call 9-1-1. Jeff is 19 years old and attending college from out-of-state. He has no local family.

Initial Assessment
Physical assessment of Jeff reveals a healthy-appearing male. He’s awake, alert and is able to respond to your questions appropriately, but his answers are short and he’s in obvious discomfort. His pulse rate is strong at 110 beats per minute. His blood pressure is 118/72 and respirations are 18 and appear uncompromised. His skin is hot and moist but he confirms he just got out of the shower.

He tells you he began experiencing lower abdominal pain toward the end of practice. He thought he’d feel better after a shower but the pain has only increased. He admits to practicing hard but denies any traumatic events. His bowel and bladder habits have been normal and he states he’s nauseated but hasn’t vomited. The pain is localized to his lower abdomen and describes it as continual and more of an ache than a sharp pain.

Physical exam reveals a normally developed abdomen with no noted distention or discoloration. The area is soft and pain doesn’t increase with palpation. Jeff then mentions the pain extends into his groin, but reassures he wasn’t struck during practice.

The Missing Piece
With this new information you ask about swelling or discoloration of his testicles, which he denies but says they’re tender. Jeff refutes any recent lesions or penile discharge and, when asked about being sexually active, says he’s “met a couple friends” since coming to college. His sly grin quickly returns to a grimace, however, as he winces with pain.

During transport Jeff holds an ice pack to his groin, which doesn’t relieve any pain. Soon after arriving at the ED, Jeff is taken to surgery for relief of testicular torsion.

Discussion
Testicular pain can be a sign of several serious conditions. Testicular torsion, as seen with Jeff, is a condition where the testicle twists within the scrotal sac, limiting it’s blood supply. If the testicle’s blood supply isn’t returned, it will need to be surgically removed.

Torsion can occur spontaneously or be associated with a traumatic event. The incidence of torsion is one in every 4,000 males under the age of 251 and is most commonly seen during the perinatal period and during puberty. When identified, it’s a surgical emergency.

Torsion may present with pain in the groin or abdomen, and nausea may be experienced.

Assessment of the groin would in some cases reveal scrotum swelling and discoloration. In the ED, manual detorsion of the affected testicle may be attempted. In some cases, this procedure is recommended for emergency wilderness care if the patient is several hours from definitive medical treatment.

Other causes of testicular pain include epididymitis and testicular cancer. Epididymitis is an infection of the epididymis, which is the tube at the back of the testicle that connects the testicle to the vas deferens. According to the National Institutes of Health, epididymitis is most commonly caused by gonorrhea and chlamydia seen in sexually active men under the age of 35.2 In older men it’s more commonly associated with bladder infections, surgical procedures and catheter placement.

The onset of epididymitis is more gradual than testicular torsion and includes scrotal and abdominal pain. The patient may describe increased pain during ejaculation and blood-tainted semen. There’s also pain associated with bowel movements and any pressure on the testicle. Other signs of infection, such as fever and chills, may exist as well.

Definitive treatment for epididymitis is antibiotics. EMS providers should provide supportive care.

Testicular cancer can present with testicular or abdominal pain. There may be swelling and a feeling of heaviness to the scrotum. The patient may also describe an abnormal shape of one testicle or a lump. EMS treatment is supportive and the patient should be transported for definitive care.

Conclusion
Testicular pain is an uncommon 9-1-1 call but patients with abdominal pain are frequently seen by EMS providers. It’s important to remember that testicular conditions can present with abdominal pain, and it’s been identified that embarrassment in prepubescent or pubertal patients may prevent disclosure of scrotal pain or the patient may not consider testicular complications as a cause of their abdominal discomfort.3 As with Jeff’s abdominal pain, further assessment revealed possible testicular involvement including several risk factors: adolescence, physical activity and several new “friends.”

Consider a testicular origin with any male presenting with abdominal pain. We’re encouraged to ask our female patients with abdominal pain if they’re sexually active, possibly pregnant, have vaginal discharge or pain with intercourse. Let’s not forget the same focus and consideration of cause should be afforded our male patients as well.

References:

1. Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. 2006;74(10):1739–1743.

2. MedlinePlus Medical Encyclopedia. (n.d.) Epididymitis. Retrieved Nov. 21, 2013, from www.nlm.nih.gov/medlineplus/ency/article/001279.htm.

3. Lopez RN, Beasley SW. Testicular torsion: Potential pitfalls in its diagnosis and management. J Paediatr Child Health. 2012;48(2):e30–e32.

Administration and Leadership

A Fine Line: Good-natured Pranks Can Easily be Considered Harassment

Issue 2 and Volume 39.

Rebecca Sedwick committed suicide by jumping from a tower at an abandoned concrete plant after enduring months of harassment and bullying by two other girls aged 12 and 14.

I couldn’t help but to be struck by her story. While tragic, we hear so often of children who are terrorized in school but seldom about adults, who are also subject to bullying, harassment and pranks.

I suppose the assumption is that they’re grown and should be able to endure whatever comes their way.

How wrong an assumption that is! There’s a fine line between harassment and good-natured pranks—especially when it comes to EMS.

Some pranks are designed to be harmless and good-natured, but others cross the line and can be considered harassment and bullying. I don’t advocate pranks of any type: Tying some pie pans to the back of an ambulance so it leaves the station among clatter can be considered harmless, but some might see it differently and believe they’re being singled out and harassed. You never know how people are going to react to being pranked.

Some EMS people love putting Vaseline on the ambulance door handles, while others like filling the back of an ambulance with balloons for two unsuspecting EMTs. One prank that’s been around since the invention of the siren is to put the siren in the “on” position. When the batteries or the engine is turned on, the siren automatically shrieks.

Putting something in someone’s food at the station or forcing them into some type of initiation definitely crosses the line. Some would contend the rule is typically: If someone can be hurt physically, emotionally or financially by a prank, it’s crossed the line. Placing Lasix in the drink of some unsuspecting paramedic pretty much crosses the line and will cost you your job.

The best policy is not to engage in any prank activity—especially if you’re in a management or supervisory position.

Pranks can be considered hazing or harassment, which is illegal and subject to lawsuits in most states. Such is the case with a woman who filed a $39 million lawsuit in May 2013 against the Baltimore County Fire Department for harassment. The allegations of harassment occurred over a two-month period when she was a recruit in the fire academy. The list of charges and specific occurrences is too long to list, but includes a recruit allegedly grabbing her breast in the presence of an instructor with no consequences to the recruit. She also alleged that she was repeatedly singled out and berated in front of other recruits.

Workplace bullying can come from peers, but it can also come from someone who has authority over the person being bullied. Patricia Barnes, author of Surviving Bullies, Queen Bees & Psychopaths in the Workplace, contends that supervisors who bully are a critical but often-overlooked problem.

The most dangerous person in authority is someone smart enough to create a hostile work environment but do it under the guise of the established rules and regulations of the organization. They make sure the harassed employee follows the rules without exception while they look the other way with others. These workplace bullies with authority are usually predictable. They usually place great emphasis and concentrate on monitoring the work performance of only those they are harassing and bullying. Even though they may have multiple employees reporting to them, they focus on a specific few, denying opportunities while showing partiality to others.

Bullying someone in the workplace from a position of authority in some cases can have consequences that go beyond the law.

If you look at past workplace active shooter cases in the United States, some of those shootings are a result of continued harassment and bullying of the assailant.

Whether bullying and harassment actually occurred or if it can be truly verified doesn’t matter—what’s important is that the assailant perceived it that way.

Some EMS organizations have specific rules against pranks and initiations. If they don’t have rules dictating how employees should professionally perform in the workplace, they need to. Having no established rules would further the case of a plaintiff in a lawsuit for harassment with their contention that the organization condoned the behavior.

If you’re an EMS manager, it’s imperative you have rules and procedures in place to prevent harassment and discrimination. Those rules and procedures can be broad enough to include pranks and practical jokes. Creating a respectful and non-hostile workplace should be a priority for any EMS organization.

Whether bullying & harassment actually occurred or if it can be truly verified doesn’t matter—what’s important is that the assailant perceived it that way.