In this case, you are presented with a patient who had a recent ERCP for choledocholithiasis. He has increasing abdominal pain, declining BP and urine output, elevated amylase and a CT indicative of acute pancreatitis, here are some points for you to think about, and my take on the issue:
Question: Does the fact that the patient doesn’t look terribly ill important?
Discussion: In some cases yes, some no. As I have said to my residents, any idiot can tell when someone is dying, the good clinician can act on problems before they are obvious. The fact that the patient is not dying just means you have more time to figure things out. If the clinical data indicates something is going on, you need to act.
Question: Do you need a CT and all those labs?
Discussion: The most devastating complication that could be occurring in this case is a duodenal perforation from the procedure. You are not going to be able to rule out that complication on physical exam, so increasing abdominal pain after ERCP warrants CT scanning (or just a flat plate to look for free air, but a CT gives you more useful information). The labs are necessary to get an idea of the status of the organ systems (renal, hematologic, etc.).
Question: Does the patient need to go to the unit?
Discussion: Dont know about your hospital, but in mine, patients at high risk for deterioration should be in the ICU or a very capable step down unit. The acute care floor simply has a nurse to patient ratio that is too high to insure that the patient will be checked on every hour or more. Also you will want a close watch on the patients hemodynamics, urine output, etc.
Question: What about all the other stuff?
Discussion: I believe you need to look for things, not wait for them to present if you have a suspicion that badness is going on. As I’ve said, if you wait, sometimes you will get behind the curve. Remember, if youre worried about costs, its a lot cheaper to look for problems and intervene early than it is to wait till patients crash and then act.