On Call Surgery On Call Series 4Th Edition Gregg A Adams MD Facs Full Chapter

On Call Surgery: On Call Series 4th
Edition Gregg A. Adams Md Facs

Visit to download the full and correct content document:
https://ebookmass.com/product/on-call-surgery-on-call-series-4th-edition-gregg-a-ada
ms-md-facs/
Any screen.
Any time.
Anywhere.
Activate the eBook version
of this title at no additional charge.
Expert Consult eBooks give you the power to browse and find
content, view enhanced images, share notes and highlights—both
online and offline.
Unlock your eBook today.

1 Visit expertconsult.inkling.com/redeem
2 Scratch off your code Scan this QR code
to redeem your
3 Type code into “Enter Code” box eBook through
your mobile device:
4 Click “Redeem”
5 Log in or Sign up
6 Go to “My Library”
It’s that easy!
Place Peel Off

Sticker Here
For technical assistance:

email expertconsult.help@elsevier.com
call 1-800-401-9962 (inside the US)
call +1-314-447-8200 (outside the US)
Use of the current edition of the electronic version of this book (eBook) is subject to the terms of
the nontransferable, limited license granted on expertconsult.inkling.com. Access to the eBook
is limited to the first individual who redeems the PIN, located on the inside cover of this book, at
expertconsult.inkling.com and may not be transferred to another party by resale, lending, or other means.
2015v1.0
ON CALL
Surgery
Be ON CALL with confidence!
Successfully managing on-call situations requires a masterful com-
bination of speed, skills, and knowledge. Rise to the occasion with
ELSEVIER’s On Call Series! These pocket-size resources provide
you with immediate access to the vital, step-by-step information
you need to succeed!
Other Titles in the ON CALL Series

Adams & Bresnick: On Call Procedures
Bernstein, Levin, Poag & Rubinstein: On Call Psychiatry
Chin: On Call Obstetrics and Gynecology
Henry & Mathur: On Call Laboratory Medicine and Pathology
Khan: On Call Cardiology
Marshall & Mayer: On Call Neurology
Marshall & Ruedy: On Call Principles and Protocols
Nocton & Gedeit: On Call Pediatrics
ON CALL
Surgery
4th Edition
GREGG A. ADAMS, MD, FACS

Chair, Department of Surgery
Santa Clara Valley Medical Center
San Jose, California
Clinical Associate Professor of Surgery

Stanford University, School of Medicine
Stanford, California
JARED A. FORRESTER, MD
General Surgery Resident
Department of Surgery
Stanford University
GRAEME M. ROSENBERG, MD
General Surgery Resident
Department of Surgery
Stanford University
STEPHEN D. BRESNICK, MD, DDS

Private Practice
Plastics and Reconstructive Surgery
Los Angeles, California
ON CALL SURGERY, FOURTH EDITION ISBN: 978-0-323-52889-4
Copyright © 2020, Elsevier Inc. All rights reserved.

Previous editions copyrighted 2006, 2001, and 1997.
No part of this publication may be reproduced or transmitted in any form or by any

means, electronic or mechanical, including photocopying, recording, or any infor-
mation storage and retrieval system, without permission in writing from the pub-
lisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright
Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copy-
right by the Publisher (other than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowl-
edge in evaluating and using any information, methods, compounds or experiments
described herein. Because of rapid advances in the medical sciences, in particular,
independent verification of diagnoses and drug dosages should be made. To the
fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of any
methods, products, instructions, or ideas contained in the material herein.
Library of Congress Control Number: 2019935212
Content Strategist: Marybeth Thiel

Content Development Specialist: Caroline Dorey-Stein
Publishing Services Manager: Shereen Jameel
Senior Project Manager: Umarani Natarajan
Design Direction: Amy Buxton
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
3251 Riverport Lane

St. Louis, Missouri 63043
GA: Dedicated to Sherri Sadler, with whom all things are possible
JF: To my family (and the friends who’ve become my family) for the
constant love, mentorship, and support
GR: To Corinne and Jack, for showing me what my true purpose is
JF & GR: Dedicated to all of our patients and the surgical team at
“The Valley” who continue to inspire the next generation of surgical
trainees
This page intentionally left blank

Preface
Medicine changes daily and requires constant learning and curi-

osity. In particular, residency training is evolving to address new
challenges such as decreased work hours and new regulatory and
privacy guidelines. “Best practices” and clinical guidelines are be-
coming prominent, and computerized health records make vast
amounts of information available without necessarily saving any
time. Despite changes within medical care delivery, patients still
have high expectations of your time and abilities. With fewer hours
to meet patients’ needs and more information available at your fin-
gertips, it is imperative that an organized approach be used to diag-
nose and treat clinical syndromes. In addition, limiting work hours
has created a situation where patients must routinely be “signed
out” to an on-call resident, placing new emphasis on communica-
tion between colleagues and consultants.
Many educational situations occur during nights spent “on
call.” Although this is a time of learning, it is also a time of stress,
owing to fatigue, heavy workloads, and decreased availability of
staff support. In addition, the on-call team may have responsibility
for patients about whom limited information is available. On Call
Surgery is designed to meet the needs of today’s surgeon. In a very
concise and organized fashion, the text will lead medical students,
residents, and practitioners of all levels through a safe and relevant
evaluation of clinical on-call problems.
vii

Acknowledgments
We acknowledge all of our teachers, including our parents, instruc-

tors, fellow residents and students, and especially our patients.
Thank you also to those who tolerated many late nights of typ-
ing and those many others who contributed, directly and indirectly,
to this work.
ix

Structure of the Book
Most medical didactic education starts with a disease process,

explaining first the pathophysiology and then revealing the clini-
cal findings. The training at the bedside, however, starts with a
physical complaint or a finding, and the underlying disease is only
revealed through careful listening, observation, and deduction.
A wide differential diagnosis is then created, recognizing that in
order to make a diagnosis, you must first think of a diagnosis. Then
the differential diagnosis is pared down using history, physical ex-
amination, and the judicious use of laboratory and radiographic
studies.
In order to more fully follow the line of thinking at the bed-
side, the structure of On Call Surgery starts with the initial phone
call from a bedside care provider, describing a patient problem.
A list of likely diagnoses is generated and a plan for assessment
and management of the patient is outlined. Particular emphasis
is placed on those diseases that pose the greatest risk to a pa-
tient and the special needs of the preoperative and postoperative
patient.
PHONE CALL
The initial phone call from the bedside care provider describes the
patient symptoms and signs.
Questions
Pertinent questions are listed that help clarify the nature and sever-
ity of the problem.
Orders
Orders or instructions that will increase the safety of the patient or
help rapidly diagnosis the patient are listed.
Not all of these orders need be used in each scenario.
Inform RN
Let the bedside care provider (often an RN) know when to expect
you at the bedside to evaluate the patient.
xi
xii Structure of the Book
ELEVATOR THOUGHTS
These are the Differential Diagnoses lists. The phrase “Elevator
Thoughts” was coined by Shane Marshall and John Ruedy in the
first edition of On Call: Principles and Protocols, in recognition that
an elevator ride often stands between you and your patient. They
encourage you to use that time wisely by thinking about the pos-
sible causes of a specific symptom or complaint.
MAJOR THREAT TO LIFE

These are those disease processes that pose the most serious risk to
the patient and must be ruled out first.
SURGICAL CHART BIOPSY

The electronic medical record allows for real-time review of trends
in objective data. It is advantageous to review this data systemati-
cally to aid in timely triage, diagnosis, and treatment.
BEDSIDE
The evaluation at the bedside is divided into various steps, starting
from the moment you walk into the room.
Quick Look Test

This is a rapid visual assessment of the patient. It should be prac-
ticed with every patient encounter. Quickly divide your patient
into one of three categories: well, sick, or critical. This will help
focus your next steps and give you a guide as to how rapidly the
remainder of the assessment needs to be made.
Airway and Vital Signs

The next evaluation of any patient is a quick assessment of the pa-
tient’s breathing, vital signs, and fluid status. Special note is made
of any recent changes or instability. Breathing or circulatory dif-
ficulties are dealt with immediately as life-threatening conditions.
Selective History, Chart Review, and Physical

Examination
Next is a limited and directed history and physical examination,
which is generally problem directed. This departs from the stan-
dard 30- to 60-minute interview practiced in medical school or
the unhurried evaluation of a new patient. The motivation is dif-
ferent when the physician is on call. A specific complaint is to be
addressed, and although that often expands into an assessment of
Structure of the Book xiii
several systems, other aspects of the patient’s care, unrelated to

the current complaint, do not need to be evaluated at this time.
Sources of pertinent information are obtained from the bedside
caregiver, from the patient, and from the chart. Remember that
much information has already been obtained and is organized
in the bedside chart, but be careful not to rely completely on this
information. Circumstances may dictate further questioning and
examination not already documented.
MANAGEMENT
Some management begins before the assessment is complete. In
such cases, the steps needed to keep a patient safe should be begun
before continuing with other steps.
The text also contains helpful Appendices and a Formulary of
commonly used medications. A comprehensive list of necessary
Formulae is also included.
The structure and content of On Call Surgery will be helpful as
points of reference and guides to the management of many of the
typical problems encountered while caring for surgical patients.
We believe that the reader will find On Call Surgery to be one of
the most valuable resources available.

Contents
INTRODUCTION
1 Approach to On-Call Surgical Problems 2

2 Special Considerations for Surgical Patients 7
3 Documentation of On-Call Problems 10
4 On-Call Hazards 15
PATIENT-RELATED PROBLEMS:
THE COMMON CALLS
5 Abdominal Pain 20
6 Bowel Function—Constipation and Diarrhea 60
7 Chest Pain 71
8 Drug Reactions 84
9 Dysrhythmias 94
10 Falls 119
11 Fever 126
12 Fluids, Electrolytes, and Acid–Base Status 136
13 Gastrointestinal Bleeding 189
14 Glucose Management and Surgical Nutrition 201
15 Headache 218
16 Hypertension 234
17 Hypotension and Shock 246
xv
xvi Table of Contents
18 Insomnia 262
19 Intravascular Access 265
20 Leg Pain 309
21 Mental Status Changes 329
22 Nausea and Vomiting 339
23 Pain Management 346
24 Preoperative Preparation 360
25 Pronouncing Death and End-of-Life Issues 373
26 Postoperative Bleeding 381
27 Seizures 392
28 Shortness of Breath 401
29 Syncope 425
30 Trauma 433
31 Tubes and Drains 458
32
Point-of-Care and Procedural Ultrasound:
For Surgical Residents511
33 Urine Output Changes 546
34 Wounds 567
APPENDICES
A Reading X-Rays, Reading ECGs 576
B Outlines of Common Surgical Notes 582
C
Abbreviations585
Index589
Introduction
CHAPTER
1
Approach to On-Call
Surgical Problems
Why write a book on surgical on-call problems? All surgical train-

ing programs require time spent “on call.” This is the time, usually
overnight or on weekends, during which a physician is responsible
for the care of hospitalized patients. It is also the time when new clini-
cal problems arise. These times have extraordinary educational value,
but are also the source of great stress. While on call, the physician
is typically among the first to encounter significant changes in the
condition of a patient and variances in recovery patterns. Hence, it is
a unique time to hone clinical skills. However, under current training
practices, a significant amount of the time spent “on call” occurs early
in the educational process and the individual may not have encoun-
tered a wide range of clinical situations. Being on call often requires
late hours and prioritizing numerous tasks. Additionally, being on call
usually involves “cross coverage,” or responsibility for patients whom
the on-call physician may have little familiarity or information. Often
life-threatening changes in a patient’s condition may be hidden un-
der seemingly innocuous symptoms. Knowledge and anticipation of
these problems may make a great difference in the patient’s outcome.
It is useful, therefore, to have a plan for evaluating and administering
care to patients in a rapid but thorough and organized fashion.
This book provides an outline for the organization and implemen-
tation of care plans in response to many on-call surgical situations. It is
written for the intern and junior resident, but we hope that the infor-
mation will be useful for individuals at all levels of training. Obviously,
not all on-call situations can be covered, but emphasis has been placed
on the more common and more life-threatening problems.
The structure of this book follows closely the flow of informa-
tion as it reaches the individual on call. Most chapters are divided
into six major headings, as follows:
Phone Call
Elevator Thoughts
2
Approach to On-Call Surgical Problems 3
Major Threat to Life

Surgical Chart Biopsy
Bedside
Management
Special Surgical Considerations
PHONE CALL
The first notification of a change in the status of a patient is often
a phone call from the bedside caregiver. During that phone call
the status of the patient and the urgency of the response must be
assessed immediately. It is important to determine whether the
patient is pre- or postoperative. If necessary, orders for immediate
action are given and initial laboratory studies are ordered. The bed-
side care provider should be given an estimate of when to expect
the physician’s arrival at the bedside. Rarely, the problem may be
handled entirely over the phone, but usually, a bedside evaluation
is required to fully assess the situation. If there is any question, al-
ways err toward a bedside evaluation. You will never be faulted for
a bedside examination; the same cannot be said for only a phone
call with a potentially sick patient.
ELEVATOR THOUGHTS
The travel time to the bedside is wisely spent in consideration of the
differential diagnosis of the presenting symptom. These are called
elevator thoughts. This term was coined by Shane A. Marshall, MD,
and John Ruedy, MD, in the first edition of On Call: Principles and
Protocols, and it refers to the long distances through the hospital that
often have to be covered while on call. Elevator thoughts also may be
used to organize a plan of action once at the bedside. The differential
diagnoses given in this text are not meant to be complete; attention is
given to those that are most common and to those that could be life
threatening. Always bear in mind that there are many uncommon
causes of symptoms that can be diagnosed or treated with simple
measures, and these must also be entertained. Know what the pre-
liminary plan of action will be before arriving at the bedside.

In many clinical situations there is a potential of serious injury or risk
to life, although these outcomes are, thankfully, uncommon. Many
patients are initially hospitalized to anticipate or treat these poten-
tial complications. This section will focus on those observations and
tests that will best ensure the safety of the patient. The major threat to
life is rarely the most common item on the differential diagnosis list.
4 Introduction
In clinical practice, it is a wise educational tool to imagine what

the major threat is to each patient each day, pre- and postoperatively,
and to outline a plan of action. Although these threats may not
become a reality, the anticipation of a bad outcome leads to appro-
priate vigilance and avoidance tactics and to suitable preparation in
the face of an unfortunate event.

The advent of the electronic medical record (EMR) allows for re-
al-time review of trends in objective data, most importantly vital
signs, fluid balance, laboratory values, and recent changes in medi-
cations.
Remember, no single data point is as meaningful as consid-
ering trends. If your hospital uses an EMR system, use it to your
advantage during workup and synthesis
When called about a problem, it is advantageous to review the
patient’s electronic chart quickly. This can narrow the questions
and directions you have for the bedside nurse. Developing famil-
iarity with your EMR and creating a systematic method for quick
review of the data will greatly aid in timely response, diagnosis,
and treatment.
Recommendations:
View the vital signs in a range by shift or over the previous 24
hours.
Note changes in heart rate, blood pressure, oxygen saturation,
and temperature.
Review the patient’s fluid balance—how much they have taken
in, and how much is coming out.
Review recent laboratory values and the direction that abnor-
mal values are trending.
Finally, synthesize all of this information. Do not treat a num-
ber; treat a constellation of symptoms. You will begin to no-
tice patterns that allow you to quickly respond to nursing
questions, changes in patient status, and emergencies.
BEDSIDE
This section deals with the evaluation of the patient at the bedside.
This evaluation may be divided into three steps.
Quick Look Test

Once at the bedside, the first look at the patient often is the best as-
sessment of the severity of the complaint. This begins as you enter
the patient’s room and involves a rapid scan of the patient’s general
condition. A patient, who is calm and conversant with stable vital
Approach to On-Call Surgical Problems 5
signs, may require less speed of action than one who is acutely
distressed or unstable. Patients may be divided into the following
three broad groups:
1. Comfortable: At ease, with stable or normal vital signs
2. Sick: Requiring attention; recent changes or abnormalities in
signs or symptoms, with an indication of patient discomfort
3. Critical: Moribund or very unstable; about to die
This “first look” should become reflexive. Practice it with every
patient contact, such as on rounds in the morning or in the clinic,
so that it becomes automatic.
Vital Signs
The next evaluation of any patient is a quick assessment of the
patient’s breathing, vital signs, and fluid status. Special note is
made of any recent changes or instability. As with any emer-
gency situation, aberrations to airway breathing or circulation
are dealt with immediately as life-threatening conditions. Fol-
low the ABCs. When in doubt, always return to the ABCs.
Selective History, Chart Review, and Physical

Examination
Next is a limited and directed history and physical examination,
which is generally problem directed. This is a departure from
the standard 30- to 60-minute interview practiced in medical
school, or the unhurried evaluation of a new patient. The mo-
tivation is different when the physician is on call. A specific
complaint is to be addressed, and although that often expands
into an assessment of several systems, other aspects of the pa-
tient’s care, unrelated to the current complaint, do not need to
be evaluated at this time. Sources of pertinent information are
obtained from the bedside caregiver, from the patient, and from
the chart.
Remember that much information has already been ob-
tained and is organized in the bedside chart or EMR, but be care-
ful not to rely completely on this information. Circumstances may
dictate further questioning and examination not already docu-
mented.
MANAGEMENT
Emergency measures and initial laboratory studies are described
in an Initial Management section.
Further management issues, based on findings in the history
and physical examination, are then discussed in the Definitive
Management section.
6 Introduction
SPECIAL SURGICAL CONSIDERATIONS

Situations in which special considerations are necessary, specific to
a particular surgical technique or patient, will be addressed within
specific sections throughout this resource. Chapter 2 discusses
general special considerations for surgical patients.
FURTHER INFORMATION
This book also has several helpful appendices that outline reading
of chest x-rays, electrocardiography, and ultrasounds and also list
commonly used formulae and medications. Wherever possible, in-
formation is placed in list or table form for quick reference.
CHAP TER
2
Special Considerations
for Surgical Patients
Surgical patients are different from other patients in the hospi-

tal. Physiologic changes in their condition that become apparent
on call may be a result of the disease process that prompted their
admission or may be a result of the surgical procedure that was
used to treat them. Often the same symptom will require differ-
ent considerations in a preoperative patient than in a postopera-
tive patient. Also important is the time elapsed since the day of the
surgery and the type of procedure performed. This section will be
devoted to considerations that are specific to the surgical patient.
Problems and considerations specific to individual surgical spe-
cialties will also be addressed.
PATIENT CONSIDERATIONS
Remember at all times to consider the needs of the patient and
not just the disease state or the surgery to be performed. Not only
will your patients and their loved ones appreciate the humanism
but you will reach higher levels of fulfillment from the work that
you do.
As elegantly said by a close friend, Sherri Sadler, on behalf of
all patients:
“Dear Doctor,
As your patient, please remember treat each one of us as an in-
dividual. Even though you may see this problem everyday, it is the
first time it is happening to me. And many of us have never been
confronted with the possibility of having an operation before. Give us
the time, consideration, and explanation that we so desperately seek.
We are frightened and we often don’t understand medical terminol-
ogy for our situation. We don’t know what questions we should ask,
and there are some questions we are too afraid to ask. And if we don’t
understand the first time, please explain it again so that we do. Tell us
what is going to happen before and after surgery, and what to expect
in the days and weeks to come. Tell us how our lives will be different.
7
8 Introduction
Some of us don’t have someone else to look out for us so please, have
someone available to answer our questions once we’ve been released
to our home care. Treat us as more than another patient with a prob-
lem. Offer us some compassion; be patient with our questions. Above
all, remember we are mothers, fathers, wives and daughters, brothers
and sons. Just like you.
Your Patient”
PREOPERATIVE CONSIDERATIONS
Preoperative patients are broadly divided into the following three
categories: elective, urgent, and emergent.
The elective patient may not be acutely ill, but may require a
surgical procedure. A good example is the patient admitted for
bowel preparation before abdominal surgery or the patient admit-
ted for diagnostic procedures. Perturbations in their health, such
as fever or chest pain, may be enough to cancel an elective proce-
dure, pending further evaluation of the problem.
The urgent patient may be more ill, and the disease state that
was the reason for admission may cause changes in the patient’s
condition. Knowledge of the pathophysiology of the disease often
will make it easier to anticipate and circumvent these problems,
but occasionally a patient’s condition will deteriorate to the point
that urgency becomes emergency.
The emergent patient requires the most immediate attention
and thought. These patients often are identified by how sick they
look, their presenting symptoms, and their physiologic parameters
such as vital signs and major laboratory abnormalities. Any pa-
tient, including an elective patient, can become an emergent pa-
tient at any time. In the assessment of the emergent patient, always
consider whether it is appropriate to move the patient to the inten-
sive care unit or to the operating room. Also ask yourself whether
you need assistance in assessing or dealing with the problem, and
call in extra help as needed. After evaluating the patient, asking
for help is an appropriate and accepted next step and not a sign of
weakness or lack of knowledge. Being on call is a learning experi-
ence, and there is no reason to avoid consulting with others, espe-
cially your senior residents or attending physicians. It is always best
to have more hands involved in the care of a critically ill patient.
Preoperative patients soon will be in the operating room, where
their condition may drastically change. Therefore preparation of the
patient for surgery should be considered when conditions allow (see
Chapter 24). Postoperative patients will do best when they have had
adequate preoperative hydration, nutrition, and pharmacologic prep-
aration. Specific considerations including preoperative antibiotic ther-
apy and bowel preparation will be addressed in subsequent chapters.
Special Considerations for Surgical Patients 9
POSTOPERATIVE CONSIDERATIONS
The delivery of anesthetic agents and the performance of major
surgical procedures may have profound physiologic effects on
a patient. Fluid shifts are common, and the patient may require
hemodynamic monitoring, fluid resuscitation, and electrolyte
measurement and correction. Specific organ physiology may be
permanently altered, as with the transplantation of a kidney or ex-
tensive bowel resection. Various surgical results may need to be
protected, such as the integrity of a new anastomosis or the blood
flow to a free-flap graft. Many postoperative considerations are
specific to the procedure performed and will be addressed in the
appropriate chapters.
Hypothermia is a common postoperative finding. Although
found mostly after extensive surgical procedures or in trauma pa-
tients, it is of general interest because it may occur in a variety of
patients, regardless of the procedure performed.
A core temperature of less than 36˚ C persisting 1 to 2 hours
postoperatively is a significant complication. It is frequent after
extensive intraabdominal procedures and in septic, seriously in-
jured, and very ill patients. Common etiologies include long peri-
ods of time with the patient’s skin or abdominal contents exposed
to subphysiologic temperatures, or massive rehydration with cool
replacement fluids.
Expect patients with hypothermia to have vasoconstriction
with an associated increase in systemic vascular resistance (SVR).
Hypothermia may contribute to tachycardia and to hyperventi-
lation, especially in the setting of shivering. Additionally, as the
patient is rewarmed, cooler peripheral beds are reperfused, which
may slow further rewarming and contribute to postoperative aci-
dosis and coagulopathy.
The treatment includes awareness of the potential for hypo-
thermia in the operating room, rapid operative procedures, warm
intravenous (IV) solutions, warmed humidified gases in ventilated
patients, and warming blankets.
Hypothermia alters mental state, affects blood coagulation, and
prolongs the half-life of many medications. It is also possible to
overcorrect in the treatment of hypothermia, and the result should
not be confused with postoperative fever (see Chapter 11).
CHAPTER
3
Documentation of
On-Call Problems
An important aspect of management of on-call problems is the

appropriate documentation of events. This is essential for the
continued efficient care of the patient. Additionally, the medi-
cal chart is a medicolegal document, and should be as accurate
and complete as possible. Documentation is required for every
patient evaluated. This may be just a short note for a simple
problem, or it may require a complete rendering of a complex
intervention. Documentation should also include pertinent in-
formation discussed with seniors or other consultant teams, if
applicable.
As shorter work hours continue to shorten and “night float”
positions become more frequent, adequate communication
about patients becomes very important. The concept of “sign
out” at the end of a shift is not an unfamiliar one to surgical
residents, but the sign out needs to be of high quality if the
on-call resident is to adequately and efficiently tend to prob-
lems in the middle of the night. Sign out of patients can be
institution specific. Regardless, there are common patient care
issues that should be discussed in the process. Sign out should
be an active process occurring in a quiet area with emphasis
on discussions of sick patients. A standardized list of patients
should be provided to the oncoming physician. The list should
include the name of the senior person on call and important
patient details, including laboratory tests and pending stud-
ies. Pending admission or transfers with basic plans should
be communicated. Additionally, if critical patients are handed
off, prompt in-person evaluation by the oncoming physician
should occur.
Transition of patient care is a skill that we could all improve.
Likewise, when something happens to a patient who is not in
your primary care, the onus is on you to adequately document the
events for the team coming on in the morning.
An example of an on-call note is as follows:
10
Documentation of On-Call Problems 11
RESIDENT ON-CALL NOTE

Remember: If you did not document it, then it did not happen.
Document succinctly what is important for quality patient care.
(Date and time)
(Chief complaint or reason for phone call)
Called by RN to evaluate patient because of fever.
(Brief history of hospital course)
The patient is a 65-year-old man who is 2 days status post-
exploratory laparotomy for presumed bowel obstruction; 20 cm
of questionably necrotic small bowel was removed, and a pri-
mary anastomosis was performed without complication. His
postoperative course has been complicated by initial shortness
of breath associated with a mild fever (38˚ C) and an oxygen
requirement on postoperative day 1, which resolved with diuret-
ics and ambulation. His course since has been uncomplicated.
He has been ambulatory without difficulty but has not yet been
ready for oral feedings. His current therapies include IV hydra-
tion with 5% dextrose in one-half normal saline (D51⁄2 NS) at
75 mL/hour, nasogastric suction, parenteral antibiotic therapy,
ambulation, and incentive spirometry.
(List current medications)
The physical examination is directed toward the evaluation of the
problem described. (Document only what you actually examined)
Vital signs (VS): Temperature: 38.6˚ C

Pulse: 107 beats/minute
Respiration: 20/minute
Blood pressure: 136 mm Hg/85 mm Hg
Head, eyes, ears, Nasogastric tube in place, normal
nose, throat nose, and throat functioning.
(HEENT): Output over the past 24 hours:
1550 mL (75 mL in the past hour).
Green, nonbloody fluid. No sinus
tenderness.
Cardiovascular Regular rate and rhythm, mild tachy-
system (CVS): cardia. No murmur.
Respiration Basilar rales with poor aeration.
(Resp): Incentive spirometer hidden in bot-
tom drawer of personal items. No
documented use since last shift.
Abdomen (Abd): Wound clean without discharge. No
erythema. Abdomen is soft, with
mild incisional tenderness. No peri-
toneal signs. No organomegaly.
12 Introduction
Urinary: No urinary catheter. Urine output is

>800 mL/shift. No dysuria com-
plaints. No tenderness over bladder
or flanks.
IV sites: No erythema. Day 2 of current site
(left dorsal hand).
Extremities: No calf tenderness. No edema. Distal
pulses intact.
Pertinent laboratory analysis, as follows, is dictated by the history
and physical examination:
Complete blood
count (CBC):
White blood cell 6700/mcL
(WBC):
Hemoglobin (Hb): 12 g/dL
Hematocrit (Hct): 42%
Platelet (Plt): 267,000/mcL
Urinalysis: No WBC, 3 to 5 red blood cells
(RBCs), occasional epithelial cells.
Negative for leukocyte esterase,
specific gravity: 1.125.
Chest x-ray: Bibasilar atelectasis without specific
infiltrate.
The diagnosis and treatment should be clear; list any further
studies that might be useful. Also list who might have been contacted.
Assessment: Probable atelectasis; must also consider pulmo-
nary infection or reaction to antibiotic therapy.
Postoperative day 2
Day 2 antibiotic therapy (list agents used).
Treatment: 1. Incentive spirometry every hour,

the importance of which was
reiterated to the patient and his
family.
2. Continue antibiotic therapy.
3. Repeat chest x-ray and CBC in
AM.
4. Consider sputum analysis.
5. Plan discussed with RN and chief
resident (time).
Documentation of On-Call Problems 13
COMMUNICATION
Complete medical care is a team approach, and adequate com-
munication is vital for consistent and appropriate treatment of
patients. It is important to document the chart in a complete and
legible fashion. Do not forget that many practitioners and oth-
er staff read and rely on the information written in the medical
record, for example, the primary care team, the nurses directly
involved in the patient’s care, the consulting teams, and occasion-
ally the patient or family. Any of these individuals may contribute
significantly to the care of the patient. Some hospitals are now
reliant on electronic medical records (EMRs). Although your leg-
ibility should not be an issue with an EMR, be sure to proofread
and avoid uncommon shorthand acronyms. Use the EMR for im-
provement in efficiency but remember that nothing substitutes
evaluating the patient yourself. Be sure to document anything
that was done to/for the patient (i.e., staples/sutures removed)
and any new orders. Communicate a brief assessment and plan. It
is important to communicate to the other providers what you are
thinking and not just a summarization of findings.
Tactics to voice concerns:
It can often times be difficult to ask “simple” questions, voice
your discomfort with a situation, or question decisions. Many fear
outing themselves as inadequate and, worse yet, fear retribution
if questioning decisions of people with authority. Keeping in the
spirit of a team-based approach to care, individuals should feel em-
powered to ask questions and speak up if they are concerned. This
is paramount if you believe there is a chance harm could occur to
a patient. A strategy to raise awareness to a situation that may need
to be reconsidered is to use “CUS” words:
I am CONCERNED…
I am UNCOMFOTABLE with…
It is a SAFETY issue…
Or a combination: “I am CONCERNED for the patient’s SAFE-
TY—it makes me UNCOMFORTABLE.”
Most people will respond to the use of these words and con-
sider what you are saying. It is especially successful when put in the
contents of patient safety.
“Loading the Boat”

We endorse a team-based approach to care. This is especially im-
portant on a surgical service where changes can occur quickly and
quick recognition and intervention is key. We like the concept of
“loading the boat,” which means do not be the only one drowning
on a sinking boat. Get more people involved when an individual
is concerned or confused and when a clinical situation is complex
14 Introduction
and rapidly changing. The goal of care should be to help the pa-
tient and care is often improved when multiple people are thinking
about the problem at hand. In our experience, asking for help is
not a sign of weakness and is often a sign of maturity and under-
standing. In practice, loading the boat starts with contacting the
senior for assistance. However, if they are unreachable, fellows and
attendings should be contacted if help is needed or situations are
dynamic and complex. It is in the best interest of patients to deliver
the highest quality care possible. High-quality care requires a team
approach. When in doubt, load the boat.
Often, medical approaches to treating patients on call represent
differences in treatment philosophies, and these may be educa-
tional. Remember as well that communication should occur in all
directions along the hierarchy of caregivers, along the hierarchy of
caregivers. This includes communication with medical students and
interns , and also with the patient, family, bedside caregivers, chief
residents, and attending physicians.”
If professional disagreements arise, air them privately, not in
the chart.
CHAP TER
4
On-Call Hazards
The practice of medicine has inherent risks. Exposure to blood-

and secretion-borne diseases are significant and should always
be considered. Specifically, the transmission of human immuno
deficiency virus (HIV) and hepatitis to a health care provider
from an infected patient, although infrequent, is always a risk.
Hepatitis B and C are other blood-borne pathogens. Hepatitis is
particularly worrisome because only a small viral inoculum can
result in disease transmission. Precautions must always be taken,
especially in those patients about whom you have no firsthand
knowledge (Table 4.1).
Before blood contact occurs, find out what the hospital poli-
cies are regarding treatment of significant blood-borne exposures.
Know where to seek first aid as required, and make sure that your
tetanus and hepatitis B vaccinations are up-to-date (Table 4.2).
Prevention and diligence are the main ways to prevent against
harmful exposure.
TABLE 4.1 Universal Precautions to Prevent Transmission of

Communicable Diseases
Universal Precautions
Because a medical history and physical examination cannot reliably identify all
patients infected with HIV or other blood-borne pathogens, blood and body
fluid precautions should be consistently used for all patients, especially
those in emergency care settings in which the risk for blood exposure is
increased and the infection status of the patient is usually not known.
Centers for Disease Control and Prevention (CDC) Standard Precautions
The CDC recommends practicing standard precautions during the care of all
patients. The precautions apply to 1) blood; 2) all bodily fluids, secretions,
and excretions, except sweat, regardless of whether or not they contain
visible blood; 3) nonintact skin; and 4) mucous membranes. Standard
precautions are designed to reduce the risk for transmission of microor-
ganisms from both recognized and unrecognized sources of infection in
hospitals.
15
16 Introduction

Communicable Diseases—cont’d
Universal Precautions
Standard precautions include the use of handwashing and using appro-
priate personal protective equipment such as gloves, gowns, masks,
whenever touching or exposure to a patient’s bodily fluids is anticipated.
(https://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html)
Recommended approach to universal precautions:
1. Use appropriate barrier protection to prevent skin and mucous membrane
exposure when exposure to blood, bodily fluids containing blood, or
other bodily fluids to which universal precautions apply (see below), is
anticipated. Wear gloves when touching blood or bodily fluids, mucous
membranes, or nonintact skin of all patients, when handling items or sur-
faces soiled with blood or body fluids, and when performing venipuncture
and other vascular access procedures. Change gloves after contact with
each patient; do not wash or disinfect gloves for reuse. Wear masks and
protective eyewear or face shields during procedures that are likely to
generate droplets of blood or other bodily fluids to prevent exposure of
mucous membranes of the mouth, nose, and eyes. Wear gowns or aprons
during procedures that are likely to generate splashes of blood or other
bodily fluids.
2. Wash hands and other skin surfaces immediately and thoroughly after
contamination with blood, bodily fluids containing blood, or other bodily
fluids to which universal precautions apply. Wash hands immediately
after gloves are removed.
3. Take care to prevent injuries when using needles, scalpels, and other
sharp instruments or devices, when handling sharp instruments after
procedures, when cleaning used instruments, and when disposing of
used needles. Do not recap needles by hand; do not remove used needles
from disposable syringes by hand; and do not bend, break, or otherwise
manipulate used needles by hand. Place used disposable syringes and
needles, scalpel blades, and other sharp items in puncture-resistant
disposal containers, which should be located as close to the use area as
is practical.
4. Although saliva has not been implicated in HIV transmission, the need for
emergency mouth-to-mouth resuscitation should be minimized by making
mouthpieces, resuscitation bags, or other ventilation devices available for
use in areas in which the need for resuscitation is predictable.
5. Health care workers with exudative lesions or weeping dermatitis should
refrain from all direct patient care and from handling patient care equip-
ment until the condition resolves.
Universal precautions are intended to supplement rather than replace recom-
mendations for routine infection control, such as handwashing and use
of gloves to prevent gross microbial contamination of hands. In addition,
implementation of universal precautions does not eliminate the need for
other category- or disease-specific isolation precautions, such as enteric
precautions for infectious diarrhea or isolation for pulmonary tuberculosis.
Universal precautions are not intended to change waste management
programs undertaken in accordance with state and local regulations.
On-Call Hazards 17

Communicable Diseases—cont’d
Use of Gloves for Phlebotomy
Gloves should be effective in reducing the incidence of blood contamination
of hands during phlebotomy (drawing of blood samples), but they cannot
prevent penetrating injuries caused by needles or other sharp instruments.
In universal precautions, all blood is assumed to be potentially infectious
for blood-borne pathogens. Gloves should always be available for those
who wish to use them for phlebotomy. In addition, the following general
guidelines apply:
1. Use gloves for performing phlebotomy.
2. Use gloves in situations in which contamination with blood may occur—
for example, when in the trauma bay or resuscitation room
3. Use gloves for performing finger or heel sticks on infants and children.
4. Use gloves when training persons to do phlebotomies.
From Rubin, R.H. (1996). Acquired immunodeficiency syndrome. In Dale, D.C., & Federman,
D.D., (Eds.), Scientific American Medicine (Section 7, Subsection XI). © 1996 Scientific Ameri-
can, Inc. All rights reserved.
TABLE 4.2 First Aid After Blood or Bodily Fluid Exposure (Do
Not Delay!)
1. Immediately clean the exposed site. For eyes and other mucous mem-
branes, flushed with sterile saline or water. Wash for 5 minutes.
2. Seek out a supervisor for instructions. A specific protocol will be in place
for your institution. Do not ignore the protocol; it is for your health and
safety.
3. Serum probably will be drawn from you and the patient from whom the
fluid originated (based on institutional protocols).
4. Consent from the patient is often necessary; follow your institution’s
protocol.
5. Make sure tetanus and hepatitis B vaccinations are up to date.
6. Follow your institution’s guidelines regarding prophylaxis against HIV,
hepatitis, and other communicable infections.
It is important to be familiar with your institutions practices and protocol
regarding exposures. Understanding the initial steps and having familiar-
ity with where to find the complete protocol will increase your chances of
effective treatment (if necessary) and prompt return to your duties.

Patient-Related
Problems:
The Common Calls
CHAPTER
5
Abdominal Pain
One of the most common calls, abdominal pain, is also one of the
most difficult to evaluate. Whole textbooks have been written on
the approach to abdominal pain in surgical patients. This chapter
is not meant to replace those books, but it will cover many of the
common calls in the hospital. Many causes of abdominal pain are
benign, but one must always consider and act swiftly on those that
require immediate attention and treatment. The first major deci-
sion to be made is whether the patient needs surgery immediately
(acute abdomen). Once that is satisfactorily decided, the remain-
der of the evaluation may be performed. Recent abdominal sur-
gery is a specific cause of abdominal pain, and it often is difficult to
differentiate between expected incisional pain and a new process
that needs attention.
PHONE CALL
Questions
1. How severe is the pain?
2. Is the pain localized or generalized?
3. Are there any changes in vital signs, such as fever, hypotension,
or tachycardia?
4. Is the patient taking pain medications or steroids?
Both of these may mask or alter pain perception.
5. Has the patient undergone a surgical procedure? If so, what was
the operation and when was it performed? Always put the pa-
tient into the framework of their postoperative day (POD). It
can help rule out the more nonthreatening etiologies such as
incisional pain from those that can cause rapid decompensa-
tion, such as an anastomotic leak, sentinel bleed, or perforation
(usually not POD 1 calls). Also be mindful that adhesion for-
mation after an abdominal procedure may cause bowel obstruc-
tion, even many years later, which may present with distention
nausea, and pain.
20
Abdominal Pain 21
6. Is a nasogastric (NG) tube in place? Is it functioning normally?

Have there been changes in the trends of volume output and
fluid characteristics?
7. Are there any other symptoms, such as vomiting, dysuria, diar-
rhea, or bloating?
Orders
If an NG tube is in place for luminal decompression and it is not
functioning, it may be flushed with 20 to 30 mL of normal saline
(NS) through the suction port and 10 to 20 mL of air through the
airport. Never put water down to sump (air) port, typically the blue
port, as it will prevent consistent functioning of the tube. Evaluate,
flush, and manipulate the NG tube yourself if the patient is being
managed for an intestinal obstruction, had a luminal perforation,
or had an anastomosis in the proximal gastrointestinal (GI) tract.
Be mindful of NG tubes that are present after surgery for an upper
GI tract operation - contact your senior resident or attending be-
fore manipulating, removing, or replacing a tube in such a patient.
If the patient is freshly postoperative and you suspect that the
incisional pain is being poorly controlled, consider additional pain
medications at this time. (Refer to Chapter 23: Pain Management.)
Degree of Urgency
If there is a significant change in vital signs or symptoms, or
if the pain is a new symptom, the patient must be evaluated
immediately. Recurrent and minor pain may be evaluated in 1
to 2 hours. All abdominal pain should be assessed by physical
examination.
ELEVATOR THOUGHTS
Localized abdominal pain
This is best organized by the location of the pain (Fig. 5.1).
Generalized abdominal pain
Many etiologies of abdominal pain have aspects of both local-
ized and generalized pain (Fig. 5.2), often with progression from
localized to generalized over time.

• Luminal perforation
• Bowel infarction
• Sepsis associated with ruptured intra-abdominal abscess or as-
cending cholangitis
• Ruptured aortic aneurysm with exsanguinating hemorrhage
22 Patient-Related Problems: The Common Calls
RIGHT UPPER QUADRANT PAIN

Gallbladder and biliary tract
Hepatitis
Hepatic abscess
Hepatomegaly due to
congestive heart failure LEFT UPPER QUADRANT PAIN
Peptic ulcer Gastritis
Pancreatitis Pancreatitis
Retrocecal appendicitis Splenic enlargement, rupture,
Renal pain infarction, aneurysm
Myocardial ischemia Renal pain
Pericarditis Myocardial ischemia
Pneumonia Pneumonia
Empyema Empyema
RIGHT LOWER QUADRANT PAIN LEFT LOWER QUADRANT PAIN

Appendicitis Diverticulitis
Intestinal obstruction Intestinal obstruction
Regional enteritis Appendicitis
Diverticulitis Leaking aneurysm
Cholecystitis Abdominal wall hematoma
Perforated ulcer Ectopic pregnancy
Leaking aneurysm Ovarian cyst or torsion
Abdominal wall hematoma Salpingitis
Ectopic pregnancy Endometriosis
Ovarian cyst or torsion Ureteral calculi
Salpingitis Renal pain
Endometriosis Seminal vesiculitis
Ureteral calculi Psoas abscess
Renal pain
Seminal vesiculitis
Psoas abscess
FIG.5.1 Common etiologies of localized abdominal pain by

quadrant. (Modified from Schwartz, S.I., Shires, G.T., & Spencer,
F.C. (1989). Principles of surgery (5th ed.). New York: McGraw-
Hill. With permission.)
Abdominal Pain 23
DIFFUSE PAIN
Peritonitis
Pancreatitis
Sickle cell crisis
Early appendicitis
Mesenteric adenitis
Mesenteric thrombosis
Gastroenteritis
Aneurysm
Colitis
Intestinal obstruction
Metabolic, toxic, and
bacterial causes
FIG. 5.2 Common etiologies of generalized abdominal pain.

(Modified from Schwartz, S.I., Shires, G.T., & Spencer, F.C. (1989).
Principles of surgery (5th ed.). New York: McGraw-Hill. With per-
mission.)

Check for new fever, tachycardia, or hypotension.
Review the fluid balance.
Has the patient been voiding? Is the patient having bowel move-
ments?
BEDSIDE
Quick Look Test
First differentiate whether the patient is acutely sick (i.e., could dete-
riorate quickly) or uncomfortable. Mild abdominal pain is associat-
ed with only minor discomfort. The more severe the pain, the more
uncomfortable the patient will appear. If the patient has an acute
abdomen, impending hypovolemic shock may be present and
the patient may be lethargic or even moribund. Patients receiv-
ing narcotic medication or steroids may be deceptively comfort-
able despite serious pathology; pain and inflammatory responses
(including fever) may be blunted. Patients with peritonitis (acute
abdomen) will be still because any movement of their abdominal
wall will cause pain. Patients with renal or biliary colic will be agi-
tated and often will have “caged cat” restlessness as they try to find
a comfortable position.
Airway and Vital Signs

Glance at the vitals, paying close attention to the heart rate (tachycar-
dia is first sign of shock), blood pressure, and work of breathing. Fever
is an indication of infection or inflammatory etiology, although it
need not be present to make such a diagnosis. Tachypnea may be
present because of a lower lobe pneumonia, or it may indicate pro-
gressive acidemia from an intraabdominal catastrophe such as ne-
crotic bowel or intraabdominal sepsis. Respiratory distress can be
a sign of an intra-abdominal process, always consider this early and
rule out before proceeding with a primary respiratory workup.
Initial Assessment
For any patient, if you approach them with the ABCs (assess air-
way, breathing, and circulation), you will not go wrong.
A preliminary assessment helps in making the final diagnosis
and deciding if the patient needs surgery immediately.
1. Assess for an acute abdomen.
A rapid examination of the ill-appearing patient is a prudent start.
Questions may be asked of the patient while the examination is
being performed. The presence of an acute abdomen is a sur-
gical emergency, and exploratory laparotomy is indicated for
diagnosis and potential repair of the problem. It is not an easy
diagnosis, but some specific clues are helpful. The presence or
absence of these symptoms individually does not make the di-
agnosis, but in combination, and taken in context with the his-
tory, a decision may be made. It is not unusual to have to make
a rapid decision without having many pieces of the puzzle.
Abdominal Distention
May be present with acute obstruction, worsening ileus, or pro-
gressive ascites.
Quiet Abdomen
This is not a sensitive diagnostic test. With respect to time manage-
ment, this can be avoided. Note that the lack of bowel sounds indi-
cates a functional ileus or peritonitis and high-pitched, rushing, or
“tinkling” bowel sounds indicate possible obstruction. However, it
often requires listening for a number of minutes to know if there
are “no bowel sounds.” Physical palpation of the abdomen is quick-
er and provides more useful information.
Peritonitis
Severe pain to palpation or rigid abdominal musculature (invol-
untary guarding) is evidence of peritoneal irritation. One simple
test is to ask the patient to cough, with the expiratory force caus-
ing peritoneal irritation and extreme pain. It also may be apparent
Abdominal Pain 25
from gentle shaking of the bed or the patient, or by percussion or

palpation of the abdomen. This may be focal as in appendicitis, or
it may be generalized as with rupture of the viscus. Rebound ten-
derness may be present but is a less specific finding.
Hypotension
1. A precipitous decrease in blood pressure associated with ab-
dominal pain is a surgical emergency. You do not need to know
the exact diagnosis before considering an exploratory laparoto-
my in a gravely ill patient.
2. Treat hypotension with aggressive fluid resuscitation, as neces-
sary. Confirm the patient has two large-bore (at least 16 gauge)
intravenous (IV) catheters for adequate fluid resuscitation. A
central venous cordis or intraosseous catheter also can be used
quickly. (See Chapters 19 and 30.)
Do a complete fluid assessment (see Chapter 12). Orthostatic
blood pressure and pulse measurements will aid in diagnosing
intravascular volume deficits. If surgical treatment is required,
the patient should receive aggressive fluid resuscitation as de-
scribed in Chapter 17 while preparations for transfer to the op-
erating room (OR) are being made.
3. If the patient does not have an acute abdomen, then the re-
mainder of the history and physical examination may be per-
formed.
4. Treat severe pain with narcotics if necessary. If a patient is in
extreme distress, there is little value in delaying management of
pain. True peritonitis will not be masked by judicious doses of
narcotic medication, and the patient will be more comfortable
during the evaluation.
Selective History and Chart Review

Gather a complete history of the pain.
Important features include the following:
1. Time of onset
Many pain syndromes change over time. A classic example is
the progression of appendicitis from periumbilical pain to
right lower quadrant (RLQ) pain. The duration of the pain
may suggest the location of the symptoms. Was the onset
sudden or gradual? Did the pain awaken the patient?
2. Location
Review Figs. 5.1 and 5.2. Note whether pain is epigastric, um-
bilical, prepubic, right or left, and upper or lower; changes
in location are important. Pain also may be difficult to
localize specifically; this is common in very old or very
young patients. Most children will point at their belly but-
tons when asked to locate the pain.
3. Radiation
Pain can radiate to the back, groin, chest, and so on (Fig. 5.3).
Radiation of pain occurs when the pain fibers from the
affected organ are supplied by nerve roots that also have
a cutaneous sensory distribution. Pain in the diaphragm
from a left lower lobe pneumonia or perisplenic abscess is
radiated to the left shoulder because of mutual innervation
by the C-3, C-4, and C-5 nerve roots.
4. Quality of the pain
Pain can be stabbing, aching, cramping, burning, and so on.
5. Fluctuations in the pain
Pain can be constant, colicky, intermittent (at what intervals?),
increasing, and so on. Solid organs tend to have constant
(“solid”) pain. Hollow organs will have pain only with peri-
stalsis and therefore result in colicky pain.
6. Factors that lessen the pain
These can include position, meals, defecation, and time.
7. Factors that make the pain worse
8. Associated symptoms
Symptoms can include fever, nausea, vomiting, dizziness, dys-
uria, jaundice, and cough.
9. Character of the vomitus, if the patient is vomiting
Clear fluid indicates obstruction proximal to the sphincter of
Oddi; bilious vomitus indicates a more distal obstruction.
Feculent material indicates a distal colonic obstruction.
Does the vomiting relate temporally to the pain? Typically
with appendicitis, pain precedes the vomiting.
10. Changes in the frequency or character of the stool
Changes can include diarrhea, constipation, or change in color
or caliber.
11. Character of the stool, if the patient has diarrhea
Bloody stools or those containing mucus indicate an invasive
enteritis or inflammatory bowel disease. Clear liquid may
indicate a viral etiology. Diarrhea is sometimes associated
with a high-grade obstruction because fluid materials are
the only types that may pass (obstructive diarrhea). Does
the diarrhea relate temporally to the pain?
12. Time of the patient’s last meal. (Also important for your an-
esthesia colleagues should an urgent trip to the OR be indi-
cated.)
Is the patient anorexic?
13. Whether the patient is passing gas
Passage of gas is largely a result of swallowed air and indicates
complete bowel continuity. A lack of flatus may indicate
ileus or obstruction.
14. Prior abdominal procedures or infections
Biliary colic
Small-gut pain
Appendicular colic Renal colic

Sensitive area in
iliac abscess
Large-bowel
pain
Perforated
duodenal ulcer
or ruptured spleen
Biliary
colic
Acute
pancreatitis,
renal colic
Uterine and
rectal pain
FIG. 5.3 Common cutaneous sites of referred pain by etiology.

(From Cope, Z. (1983). Cope’s early diagnosis of the acute ab-
domen (16th ed.) (pp. 11, 141). Silen, W. (Ed.). Oxford: Oxford
University Press. With permission.)
Another random document with
no related content on Scribd:
which the spermatozoa are packed; they are often very large and assume
characteristic shapes, especially in the Decapoda.
The spermatozoa show a great variety of structure, but they conform to
two chief types—the filiform, which are provided with a long whip-like
flagellum; and the amoeboid, which are furnished with radiating
pseudopodia, and are much slower in their movements. The amoeboid
spermatozoa of some of the Decapoda contain in the cell-body a peculiar
chitinous capsule, and Koltzoff[12] has observed that when the
spermatozoon has settled upon the surface of the egg the chitinous
capsule becomes suddenly exceedingly hygroscopic, swells up, and
explodes, driving the head of the spermatozoon into the egg. We cannot
enter here into a description of the embryological changes by which the
egg is converted into the adult form. Crustacean eggs as a whole contain a
large quantity of yolk, but in some forms total segmentation occurs in the
early stages, which is converted later into the pyramidal type, i.e. the
blastomeres are arranged round the edge, and the yolk in the centre is
only partly segmented to correspond with them. The eggs during the early
stages of development are in almost all cases (except Branchiura, p. 77,
and Anaspides, p. 116) carried about by the female either in a brood-
pouch (Branchiopoda, Ostracoda, Cirripedia, Phyllocarida, Peracarida),
or agglutinated to the hind legs or some other part of the body (Copepoda,
Eucarida), or in a chamber formed from the maxillipedes (Stomatopoda).
Development may be direct, without a complicated metamorphosis, or
indirect, the larva hatching out in a form totally different to the adult
state, and attaining the latter by a series of transformations and moults.
The various larval forms will be described under the headings of the
several orders.
The respiratory organs are typically branchiae, i.e. branched
filamentous or foliaceous processes of the body-surface through which
the blood circulates, and is brought into close relation with the oxygen
dissolved in the water. In most of the smaller Entomostraca no special
branchiae are present, the interchange of gases taking place over the
whole body-surface; but in the Malacostraca the gills may reach a high
degree of specialisation. They are usually attached to the bases of the
thoracic limbs (“podobranchiae”), to the body-wall at the bases of these
limbs, often in two series (“arthrobranchiae”), and to the body-wall some
way above the limb-articulations (“pleurobranchiae”). In an ideal scheme
each thoracic appendage beginning with the first maxillipede would
possess a podobranch, two arthrobranchs, and a pleurobranch, but the
full complement of gills is never present, various members of the series
being suppressed in the various orders, and thus giving rise to “branchial
formulae” typical of the different groups.
After this brief survey of Crustacean organisation we may be able to
form an opinion upon the position of the Crustacea relative to other
Arthropoda, and upon the question debated some time ago in the pages of
Natural Science[13] whether the Arthropoda constitute a natural group.
The Crustacea plainly agree with all the other Arthropoda in the
possession of a rigid exoskeleton segmented into a number of somites, in
the possession of jointed appendages metamerically repeated, some of
which are modified to act as jaws; they further agree in the general
correspondence of the number of segments of which the body is
primitively composed; the condition of the body-cavity or haemocoel is
also similar in the adult state. An apparently fundamental difference is
found in the entire absence during development of a segmented coelom,
but since this organ breaks down and is much reduced in all adult
Arthropods, it is not difficult to believe that its actual formation in the
embryo as a distinct structure might have been secondarily suppressed in
Crustacea.
The method of breathing by gills is paralleled by the respiratory
structures found in Limulus and Scorpions; the transition, if it occurred,
from branchiae to tracheae cannot, it is true, be traced, but the separation
of Arthropods into phyletically distinct groups of Tracheata and
Branchiata on this single characteristic is inadmissible. On the whole the
Crustacea may be considered as Arthropods whose progenitors are to be
sought for among the Trilobita, from whose near relations also probably
sprang Limulus and the Arachnids.
CHAPTER II
CRUSTACEA (CONTINUED): ENTOMOSTRACA
—BRANCHIOPODA—PHYLLOPODA—
CLADOCERA—WATER-FLEAS
SUB-CLASS I.—ENTOMOSTRACA.
The Entomostraca are mostly small Crustacea in which the

segmentation of the body behind the head is very variable, both in regard
to the number of segments and the kind of differentiation exhibited by
those segments and their appendages. An unpaired simple eye, known as
the Nauplius eye from its universal presence in that larval form, often
persists in the adult, and though lateral compound eyes may be present
they are rarely borne on movable stalks. In the adult the excretory gland
(“shell-gland”) opens on the second maxillary segment, but in the larval
state or early stages of development a second antennary gland may also
be present, which disappears in the adult. The liver usually points
forwards, and is simple and saccular in structure, and the stomach is not
complicated by the formation of a gastric mill. With the exception of most
Cladocera and Ostracoda the young hatch out in the Nauplius state.
Order I. Branchiopoda.[14]
The Branchiopods are of small or moderate size, with flattened and

lobate post-cephalic limbs, and with functional gnathobases. Median and
lateral eyes are nearly always present. The labrum is large, and the second
maxillae are small or absent in the adult.
Branchiopods are found in every part of the world; a few are marine,
but the great majority are confined to inland lakes and ponds, or to
slowly-moving streams. The fresh waters, from the smallest pools to the
largest lakes, often swarm with them, as do those streams which flow so
slowly that the creatures can obtain occasional shelter among vegetation
along the sides and bottom without being swept away, while even rivers of
considerable swiftness contain some Cladocera. Several Branchiopods are
found in the brackish waters of estuaries, and some occur in lakes and
pools so salt that no other Crustacea, and few other animals of any kind,
can live in them. The great majority swim about with the back
downwards, collecting food in the ventral groove between their post-oral
limbs, and driving it forwards, towards the mouth, by movements of the
gnathobases (p. 10). The food collected in this way consists largely of
suspended organic mud, together with Diatoms and other Algae, and
Infusoria; the larger kinds, however, are capable of gnawing objects of
considerable size, Apus being said to nibble the softer insect larvae, and
even tadpoles. Many Cladocera (e.g. Daphnia, Simocephalus) may be
seen to sink to the bottom of an aquarium, with the ventral surface
downwards, and to collect mud, or even to devour the dead bodies of their
fellows, while Leptodora is said to feed upon living Copepods, which it
catches by means of its antennae.
The Branchiopoda fall naturally into two Sub-orders, the Phyllopoda
including a series of long-bodied forms, with at least ten pairs of post-
cephalic limbs, and the Cladocera with shorter bodies and not more
than six pairs of post-cephalic limbs.
Sub-Order 1. Phyllopoda.
The Phyllopoda include a series of genera which differ greatly in

appearance, owing to differences in the development of the carapace,
which are curiously correlated with differences in the position of the eyes.
Except in these points, the three families which the sub-order contains
are so much alike that they may conveniently be described together.
In the Branchipodidae the carapace is practically absent, being
represented only by the slight backward projection on each side of the
head which contains the kidney (Fig. 2); the paired eyes are supported on
mobile stalks, and project freely, one on either side of the head.
In the Apodidae[15] the head is broad and depressed, the ventral side
being nearly flat, the dorsal surface convex; the hinder margin of the head
is indicated dorsally by a transverse cervical ridge, bounded by two
grooves, behind which the carapace projects backwards as a great shield,
covering at least half the body, but attached only to the back of the head.
In Lepidurus productus the head and carapace together form an oval
expansion, deeply emarginate at the hinder, narrower end, the sides of
the emargination being toothed. The carapace has a strong median keel.
The kidneys project into the space between the folds of skin which form
the carapace, and their coils can be seen on each side, the terminal part of
each kidney-tube entering the head to open at the base of the second
maxilla. In all Branchiopoda with a well-developed carapace the kidney is
enclosed in it in this way, whence the older anatomists speak of it as the
“shell-gland.”
Fig. 2.—Chirocephalus diaphanus, female, × 5, Sussex. D.O, Dorsal
organ; H, heart; Ov, ovary; U, uterus; V, external generative opening.
Associated with the development of the carapace, in this and in the next
family, is a remarkable condition of the lateral eyes, which are sessile on
the dorsal surface of the head, and near the middle line, the median eye
being slightly in front of them. During embryonic life a fold of skin grows
over all three eyes, so that a chamber is formed over them, which
communicates with the exterior by a small pore in front.
In the Limnadiidae the body is laterally compressed, and the carapace
is so large that at least the post-cephalic part of the body, and generally
the head also, can be enclosed within it.
In Limnetis (Fig. 3) the dorsal
surface of the head is bent
downwards and is much
compressed, the carapace being
attached to it only for a short
distance near the dorsal middle line.
The sides of the carapace are bent
downwards, and their margins can
be pulled together by a transverse
adductor muscle, so that the whole
structure forms an ovoid or
spheroidal case, from which the
head projects in front, while the rest
Fig. 3.—Limnetis brachyura, × 15. (After
of the body is entirely contained G. O. Sars.)
within it. When the adductor muscle
is relaxed the edges of the carapace
gape slightly, like the valves of a Lamellibranch shell, and food-particles
are drawn through the opening thus formed into the ventral groove by the
movements of the thoracic feet, locomotion being chiefly effected by the
rowing action of the second antennae, as in the Cladocera, to which all the
Limnadiidae present strong resemblances in their method of locomotion,
in the condition of the carapace, and in the form of the telson.
In Limnadia and Estheria the carapace projects not only backwards
from the point of attachment to the head, but also forwards, so that the
head can be enclosed by it, together with the rest of the body.
In all these genera the carapace is flexible along the middle dorsal line;
in Estheria especially the softening of the dorsal cuticle goes so far that a
definite hinge-line is formed, and this, together with the deposition of the
lateral cuticle in lines concentrically arranged round a projecting umbo,
gives the carapace a strong superficial likeness to a Lamellibranch shell,
for which it is said to be frequently mistaken by collectors.
The eyes of the Limnadiidae are enclosed in a chamber formed by a
growth of skin over them, as in Apodidae, but the pore by which this
chamber communicates with the exterior is even more minute than in
Apus. The paired eyes are so close together that they may touch
(Limnadia, Estheria) or fuse (Limnetis); they are farther back than in the
Apodidae, while the ventral curvature of the head causes the median eye
to lie below them. In all these points the eyes of the Limnadiidae are
intermediate between those of Apus and those of the Cladocera.
Dorsal Organ.—A structure very characteristic of adult Phyllopods is
the “dorsal organ” (Figs. 2, 5, D.O), whose function is in many cases
obscure. It is always a patch of modified cephalic ectoderm, supplied by a
nerve from the anterior ventral lobe of the brain on each side; but its
characters, and apparent function, differ in different forms. In the
Branchipodidae the dorsal organ is a circular patch, far forward on the
surface of the head (Figs. 2, 5, D.O). Its cells are arranged in groups,
which remind one of the retinulae in a compound eye; each cell contains a
solid concretion, and the concretions of a group may be so placed as to
look like a badly-formed rhabdom. Claus,[16] who first called attention to
this structure in the Branchipodidae, regarded it as a sense-organ. In
Apodidae the dorsal organ is an oval patch of columnar ectoderm,
immediately behind the eyes; it is slightly raised above the surrounding
skin, and is covered by a very delicate cuticle (with an opening to the
exterior?), and below it is a mass of connective tissue permeated by blood;
Bernard has suggested that it is an excretory organ.
Most Limnadiidae resemble the Cladocera in the possession of a
“dorsal organ” quite distinct from the above; in Limnetis and Estheria it
has the form of a small pit, lined by an apparently glandular ectoderm,
and this is its condition in many Cladocera; in Limnadia lenticularis it is
a patch of glandular epithelium on a raised papilla. Limnadia has been
observed to anchor itself to foreign objects by pressing its dorsal organ
against them, and many Cladocera do the same thing; Sida crystallina,
for example, will remain for hours attached by its dorsal organ to a
waterweed or to the side of an aquarium. Structures resembling a dorsal
organ occur in the larvae of many other Crustacea, but the presence of
this organ in the adult is confined to Branchiopods, and indeed in many
Cladocera it disappears before maturity. It is certain that the sensory and
adhesive types of dorsal organ are not homologous, especially as
rudimentary sense-organs may exist on the head of Cladocera together
with the adhesive organ.
The telson differs considerably in the different genera. In the
Branchipodidae[17] the anus opens directly backwards; and the telson
carries two flattened backwardly directed plates, one on each side of the
anus, the margins of each plate being fringed with plumose setae. In
Artemia the anal plates are rarely as large as in Branchipus, and never
have their margins completely fringed with setae; in A. salina from
Western Europe, and in A. fertilis (Fig. 4, A) from the Great Salt Lake of
Utah, there is a variable number of setae round the apical half of each
lobe, but in specimens of A. salina from Western Siberia the number of
setae may be very small, or they may be absent; in the closely allied A.
urmiana from Persia the anal lobes are well developed in the male, each
lobe bearing a single terminal hair, but they are altogether absent in the
female. Schmankewitch and Bateson have shown that there is a certain
relation between the salinity of the water in which Artemia salina occurs
and the condition of the anal lobes, specimens from denser waters having
on the whole fewer setae; the relation is, however, evidently very complex,
and further evidence is wanted before any more definite statements can
be made.
Fig. 4.—A, Ventral view of the anal region in Artemia fertilis, from the
Great Salt Lake; B, ventral view of the telson and neighbouring parts of
Lepidurus productus; C, side view of the telson and left anal lobe of
Estheria (sp.?).
In the Apodidae the anal lobes have the form of two-jointed cirri, often
of considerable length; in Apus the anus is terminal, but in Lepidurus
(Fig. 4, B) the dorsal part of the telson is prolonged backwards, so as to
form a plate, on the ventral face of which the anus opens, much as in the
Malacostraca.
In the Limnadiidae (Fig. 4, C) the telson is laterally compressed and
produced, on each side of the anus, into a flattened, upwardly curved
process, sharply pointed posteriorly, and often serrate; the anal lobes are
represented by two stout curved spines, while in place of the dorsal
prolongation of Lepidurus we find two long plumose setae above the
anus. In the characters of the telson and anal lobes, as in those of the
head, the Limnadiidae approximate to the Cladocera. In Limnetis
brachyura the ventral face of the telson is produced into a plate
projecting backwards below the anus, in a manner which has no exact
parallel among other Crustacea.
The appendages of the Phyllopoda are fairly uniform in character,
except those affected by the sexual dimorphism, which is usually great.
Fig. 5.—Chirocephalus diaphanus, male. Side view of head, showing
the large second antenna, A2, with its appendage Ap, above which is
seen the filiform first antenna; D.O, dorsal organ; E1, median eye.
Of the cephalic appendages, the first antennae are generally small, and
are never biramous; in Branchipus and its allies they are simple unjointed
rods, in some species of Artemia they are three-jointed, in Apus they are
feebly divided into two joints, while in Estheria they are many-jointed.
The second antennae are the principal organs of locomotion in the
Limnadiidae, where they are large and biramous; in all other Phyllopoda
they are uniramous in the female, being either unjointed triangular plates
as in Chirocephalus (Fig. 2), or minute vestigial filaments as in Apus, in
which genus Zaddach, Huxley, and Claus have all failed to find any trace
of a second antenna in some females. In the male Branchipodidae the
second antennae are modified to form claspers, by which the female is
seized, the various degrees of complication which these claspers exhibit
affording convenient generic characters. In Branchinecta each second
antenna is a thick, three-jointed rod, the last joint forming a claw, while
the second joint is serrate on its inner margin; in Branchipus the base is
much thickened, and bears on its inner side a large filament (perhaps
represented by the proximal tubercle of Branchinecta and Artemia),
which looks like an extra antenna. In Streptocephalus the terminal joint
of the antenna is bifid, and there is a basal filament like that of
Branchipus; in Chirocephalus
diaphanus (Figs. 5, 6) the main
branch of the antenna consists of
two large joints, the terminal joint
being a strong claw with a serrated
process at its base, while the
proximal joint bears two
appendages on its inner side; one of
these is a small, subconical tubercle,
the second is more complicated,
consisting of a main stem and five
outgrowths. The main stem is
many-jointed and flexible, its basal
joint being longer than the others,
and bearing on its outer side a large,
triangular, membranous appendage,
and four soft cylindrical
appendages, the main stem and its
appendages being beset with
curious tubercles, ending in short
spines, whose structure is not
understood. Except during the act of
copulation this remarkable Fig. 6.—Chirocephalus diaphanus.
Second antenna of male, uncoiled.
apparatus is coiled on the inner side
of the antennary claw, the jointed
stem being so coiled that it is often compared to the coiled proboscis of a
butterfly, and the triangular membrane folded like a fan beside it, so that
much of the organ is concealed, and the general appearance of the head is
that shown in Fig. 5. During copulation, the whole structure is widely
extended.
The males of Artemia (Fig. 7) have the second antenna two-jointed, the
basal joint bearing an inner tubercle, the terminal joint being flattened
and bluntly pointed, its outer margin provided with a membranous
outgrowth. In A. fertilis the breadth of the second joint varies greatly, the
narrower forms presenting a certain remote resemblance to
Branchinecta. In the males of Polyartemia the second antennae have a
remarkable branched form not easily comparable with that found in other
Branchipodidae.
The cephalic jaws are fairly uniform throughout the order. The
mandibles have an undivided molar surface, and no palp; the first maxilla
is very generally a triangular plate, with a setose biting edge; mandibles
and maxillae are covered by the
labrum. The second maxilla
generally lies outside the chamber
formed by the labrum, and is a
simple oval plate, with or without a
special process for the duct of the
kidney.
The thoracic limbs, in front of the
genital segments, are not as a rule
differentiated into anterior
Fig. 7.—Artemia fertilis. Front view of the maxillipedes and posterior
head of a male, showing the large second locomotive appendages, as in higher
antennae, A.2; A.1, first antennae. forms; we have seen, however, that
all these limbs take part in the
prehension of food, and except in
the Limnadiidae they all assist in locomotion. One of the middle thoracic
legs of Artemia (Fig. 8, A) has a flattened stem, with seven processes on
its inner, and two on its outer margin. The gnathobase (gn) is large, and
fringed with long plumose setae, each of which is jointed; this is followed
by four smaller “endites” (or processes on the median side), and then by
two larger ones, the terminal endite (the sixth, excluding the gnathobase)
being very mobile and attached to the main stem by a definite joint. On
the outer side are two processes; a proximal “bract,” a flat plate with
crenate edges, partly divided by a constriction into two, and a distal
process, cylindrical and vascular, called by Sars and others the
“epipodite.” In other Branchipodidae we have essentially the same
condition, except that the fifth endite often becomes much larger than in
Artemia, throwing the terminal endite well over to the outer edge of the
limb; such a shift as this, continued farther, might well lead to the
condition found in the Limnadiidae, or Apodidae, where the lobe which
seems to represent the terminal endite of Artemia is entirely on the outer
border of the limb, forming what most writers have called the exopodite
(Lankester’s “flabellum”).[18] In the two last-named families the basal
exite or bract of the Branchipodidae does not appear to be represented.
Fig. 8.—A, Thoracic limb of Chirocephalus diaphanus; B, prehensile
thoracic limb of male Estheria. gn, Gnathobase; 1–6, the more distal
endites.
The limbs of the Apodidae are remarkable in two ways; those in front of
the genital opening (very constantly ten pairs) are not so nearly alike as in
most genera of the sub-order, the first two pairs especially having the axis
definitely jointed, while the endites are elongated and antenniform;
further, while the first eleven segments bear each a single pair of limbs, as
is usual among Crustacea, many of the post-genital segments bear several
pairs; thus in Apus cancriformis there are thirty-two post-cephalic
segments in front of the telson, the first eleven having each one pair of
limbs, while the next seventeen have fifty-two pairs between them, the
last four segments having none.
In all the Phyllopoda some of the post-cephalic limbs are modified for
reproductive purposes; in the Branchipodidae the last two pairs (the 12th
and 13th generally, the 20th and 21st in Polyartemia) are so modified in
both sexes. In the female these appendages fuse at an early period of
larval life, and surround the median opening of the generative duct (Fig.
2); in the male the two pairs also fuse, but traces of the limbs are left as
eversible processes round the paired openings of the vasa deferentia.
In the other families, one or more limbs of the female are adapted for
carrying or supporting the eggs. In the Apodidae the appendages of the
eleventh segment have the exopodite in the form of a rounded,
watchglass-shaped plate, fitting over a similarly shaped process of the
axis of the limb, so that a lens-shaped box is formed, into which the eggs
pass from the oviduct. In Limnadiidae the eggs are carried in masses
between the body and the carapace, and are kept in position by special
elongations of the exopodites of two or three legs, either those near the
middle of the thorax (Estheria, Limnadia), or at its posterior end
(Limnetis). In female Limnetis the last thoracic segments bear two
remarkable lateral plates, which apparently also help to support the eggs.
In the male Limnadiidae, the first (Limnetis) or the first two thoracic feet
(Limnadia, Estheria) are prehensile (Fig. 8, B).
Alimentary Canal.—The mouth of the Phyllopoda is overhung by the
large labrum, so that a kind of atrium is formed, outside the mouth itself,
in which mastication is performed; numerous unicellular glands, opening
on the oral face of the labrum, pour their secretion into the atrial
chamber, and may be called salivary, though the nature of their secretion
is not known. The mouth has commonly two swollen and setose lips,
running longitudinally forwards from the bases of the first maxillae, and
often wrapping round the blades of the mandibles. It leads into a vertical
oesophagus, which opens into a small globular stomach, lying entirely
within the head; the terminal part of the oesophagus is slightly
invaginated into the stomach, so that a valvular ring is formed at the
junction of the two. The stomach opens widely behind into a straight
intestine, which runs backwards to about the level of the telson, where it
joins a short rectum, leading to the terminal or ventral anus. The stomach
and intestine are lined by a columnar epithelium, and covered by a thin
network of circularly arranged muscle-fibres; the rectum has a flatter
epithelium, and radial muscles pass from it to the body-wall, so that it can
be dilated. The only special digestive glands are two branched glandular
tubes, situated entirely within the head, which open into the stomach by
large ducts, one on each side. In Chirocephalus the gastric glands are
fairly small and simple; in the Apodidae their branches are more complex
and form a considerable mass, filling all that portion of the head which is
not occupied by the nervous system and the muscles. Backwardly directed
gastric glands, like those of the higher Crustacea, are not found in
Branchiopods; both forms occur together in the genus Nebalia, but with
this exception the forwardly-directed glands are peculiar to
Branchiopods.
Heart.—In Branchipus and its allies, and in Artemia, the heart
extends from the first thoracic segment to the penultimate segment of the
body, and is provided with eighteen pairs of lateral openings, one pair in
every segment through which it passes except the last; it is widely open at
its hinder end, and is prolonged in front for a short distance as a cephalic
aorta, the rest of the blood-spaces being lacunar.
In most, at least, of the other Branchiopods, the heart is closed behind
and is shortened; in Apus and Lepidurus it only extends through the first
eleven post-cephalic segments, while in the Limnadiidae it is shorter still,
the heart of Limnetis passing through four segments only. In all cases
there is a pair of lateral openings in every segment traversed by the heart.
The blood of the Branchipodidae and Apodidae contains dissolved
haemoglobin, the quantity present being so small as to give but a faint
colour to the blood in Branchipus, while Artemia has rather more, and
the blood of Apus is very red. The only other Crustacea in which the blood
contains haemoglobin are the Copepods of the genus Lernanthropus,[19]
so that the appearance of this substance is as irregular and inexplicable in
Crustacea as in Chaetopods and Molluscs.
The nervous system of Branchipus may be described as an
illustration of the condition prevailing in the group. The brain consists of
two closely united ganglia, in each of which three main regions may be
distinguished; a ventral anterior lobe, a dorsal anterior lobe, and a
posterior lobe. The ventral anterior lobes give off nerves to the median
eye, to the dorsal organ, and to a pair of curious sense-organs,
comparable with the larval sense-knobs of many higher forms, situated
one on each side of the median eye; in late larvae Claus describes the
terminal apparatus of each frontal sense-organ as a single large
hypodermic cell; W. K. Spencer[20] has lately described several terminal
cells, containing peculiar chitinous bodies, in the adult. The homologous
sense-organs of Limnetis are apparently olfactory. The dorsal anterior
lobes give off the large nerves to the lateral eyes, while the posterior lobes
supply the first antennae. The oesophageal connectives have a coating of
ganglion-cells, and some of these form the ganglion of the second
antenna, the nerve to this appendage leaving the connective just behind
the brain. The post-oral nerve-cords are widely separate, each of them
dilating into a ganglion opposite every appendage, the two ganglia being
connected by two transverse commissures. The ganglia of the three
cephalic jaws, so often fused in the higher Crustacea, are here perfectly
distinct. Closely connected with each thoracic ganglion is a remarkable
unicellular gland, opening to the exterior near the middle ventral line; it
is conceivable that these cells may be properly compared with the larval
nephridia of a Chaetopod,[21] but no evidence in support of such a
comparison has yet been adduced.
Behind the genital segments, where there are no limbs, the nerve-cords
run backwards without dilating into segmental ganglia, except in the
anterior two abdominal segments where small ganglionic enlargements
occur. In Apodidae, on the other hand, those segments which carry more
than one pair of appendages have as many pairs of ganglia, united by
transverse commissures, as they have limbs.
A stomatogastric nervous system exists in Apus, where a nerve arises
on each side from the first post-oral commissure, and runs forward to join
its fellow of the opposite side on the anterior wall of the oesophagus.
From the loop so formed a larger median and a series of smaller lateral
nerves pass to the wall of the alimentary canal. A second nerve to the
oesophagus is given off from the mandibular ganglion of each side.
Reproductive Organs.—In Chirocephalus the ovaries (Fig. 2, Ov)
are hollow epithelial tubes, lying one on each side of the alimentary canal,
and extending from the sixth abdominal segment forwards to the level of
the genital opening; at this point the two ovaries are continuous with
ducts, which bend sharply downwards and open into the single uterus
contained within the projecting egg-pouch and opening to the exterior at
the apex of that organ. Short diverticula of the walls of the uterus receive
the ducts of groups of unicellular glands, the bodies of which contain a
peculiar opaque secretion, said to form the eggshells. In Apodidae the
ovaries are similar in structure, but they are much larger and branch in a
complex manner, while each ovary opens to the exterior independently of
the other in the eleventh post-cephalic segment; nothing like the median
uterus of the Branchipodidae being formed. The epithelium of the ovarian
tubes proliferates, and groups of cells are formed; one becoming an ovum,
the others being nutrient cells like those which will be more fully
described in the Cladocera.
In Chirocephalus the testes are tubes similar in shape and position to
the ovaries, each communicating in front with a short vas deferens, which
dilates into a vesicula seminalis on its way to the eversible penis; an
essentially similar arrangement is found in all Branchipodidae, but in
Apodidae and Limnadiidae there is no penis.
All the Branchiopoda are dioecious,[22] and many are parthenogenetic.
Among Branchipodidae Artemia is the only genus known to be
parthenogenetic, but parthenogenesis is common in all Apodidae, while
the males of several species of Limnadia are still unknown, although the
females are sometimes exceedingly common. In Artemia, generations in
which the males are about as numerous as the females seem to alternate
fairly quickly with others which contain only parthenogenetic females; in
Apus males are rarely abundant, and often absent for long periods; during
five consecutive years von Siebold failed to discover a male in a locality in
Bavaria, though he examined many thousands of individuals; near
Breslau he found on one occasion about 11 per cent of males (114 in 1026),
but in a subsequent year he found less than 1 per cent; the greatest
recorded percentage of males is that observed by Lubbock in 1863, when
he found 33 males among 72 individuals taken near Rouen.
The eggs of most genera can resist prolonged periods of desiccation,
and indeed it seems necessary for the development of many species that
the eggs should be first dried and afterwards placed in water. Many eggs
(e.g. of Chirocephalus diaphanus and Branchipus stagnalis) float when
placed in water after desiccation, the development taking place at the
surface of the water.
Habitat.—All the Phyllopoda, except Artemia, are confined to
stagnant shallow waters, especially to such ponds as are formed during
spring rains, and dry up during the summer. In waters of this kind the
species of Branchipus, Apus, etc., develop rapidly, and produce great
numbers of eggs, which are left in the dried mud at the bottom after
evaporation of the water, where they remain quiescent until a fresh rainy
season. The mud from the beds of such temporary pools often contains
large numbers of eggs, which may be carried by wind, on the legs of birds,
and by other means, to considerable distances. Many exotic species have
been made known to European naturalists by their power of hatching out
when mud brought home by travellers is placed in water. The water of
stagnant pools quickly dissolves a certain quantity of solid matter from
the soil, and often receives dissolved solids through surface drainage from
the neighbouring land; such salts may remain as the water evaporates, so
that the water which remains after evaporation has proceeded for some
time may be very sensibly denser than that in which the Branchiopods
were hatched; these creatures must therefore be able to endure a
considerable increase in the salinity of the surrounding waters during the
course of their lives. My friend Mr. W. W. Fisher points out that the
plants present in such a pond would often precipitate the carbonate of
lime, so that this might be removed as evaporation went on, but that
chlorides would probably remain in solution; from analyses which Mr.
Fisher has been kind enough to make for me, it is seen that this happened
in a small aquarium in my laboratory, in which Chirocephalus diaphanus
lived for four months. In April, mud from the dry bed of a pond, known to
contain eggs of Chirocephalus, was placed in this aquarium in Oxford,
and water was added from the tap. Oxford tap-water contains about 0·3
grm. salts per litre, the chlorine being equivalent to 0·023 grm. NaCl.
Water was added from time to time during May and June, but in July
evaporation was allowed to proceed unchecked. At the end of July there
was about half the original volume of water, the Chirocephalus being still
active; the residue contained 0·96 grm. dissolved solids per litre, with
chlorine equal to 0·19 grm. NaCl, so that the percentage of chlorides was
about eight times the initial percentage, but there were only three and a
fifth times the original amount of total solid matter in solution, the
carbonate of lime having precipitated as a visible film.
Some species of Branchipus (e.g. B. spinosus, M. Edw.) and of Estheria
(E. macgillivrayi, Baird, E. gubernator, Klutzinger) occur in salt pools,
but Artemia flourishes in waters beside whose salinity that endured by
any other Branchiopod is insignificant. In the South of Europe, Artemia
salina may be found in swarms, as it used to be found in Dorsetshire, in
the shallow brine-pans from which salt is commercially prepared; Rathke
quotes an analysis showing that a pool in the Crimea contained living
Artemia when the salts in solution were 271 grms. per litre, and the water
was said to have the colour and consistency of beer.
The behaviour of the animals in the water differs a little; in normal
feeding all the species swim with the back downwards, as has already
been said; the Branchipodidae rarely settle on the ground, or on foreign
objects, but the Apodidae occasionally wriggle along the bottom on their
ventral surface, and Estheria burrows in mud.
The greater number of species are found in pools in flat, low-lying
regions, and many appear to be especially abundant near the sea; Apus
cancriformis has, however, been found in Armenia at 10,000 feet above
sea level.
Wells and underground waters do not generally contain Phyllopods;
but a species of Branchipus and one of Limnetis, both blind, have been
described from the caves of Carniola.
One of the many puzzles presented by these creatures is the erratic way
in which they are scattered through the regions they inhabit; a single
small pond, a few yards or less in diameter, may be the only place within
many miles in which a given species can be found; in this pond it may,
however, appear regularly season after season for some time, and then
suddenly vanish.
Geographically, the Phyllopoda are cosmopolitan, representatives of
every family and of some genera (e.g. Streptocephalus, Lepidurus,
Estheria) being found in every one of the great zoological regions, though
a few aberrant genera are of limited range, thus Polyartemia is known
only from the northern Palaearctic and Nearctic regions,
Thamnocephalus only from the Central United States. The genus Artemia
is not at present known in Australia.[23] The only recorded British species
are Chirocephalus diaphanus, Artemia salina, and Apus cancriformis,[24]
but other continental islands, for example the West Indian group, are
better supplied. The distribution of the species is very imperfectly known,
but on the whole every main zoological region seems to have its own
peculiar species, which do not pass beyond its boundaries. Branchinecta
paludosa and Lepidurus glacialis are circumpolar, both occurring in
Norway, in Lapland, in Greenland, and in Arctic North America; but with
these exceptions the Palaearctic and Nearctic species seem to be distinct.
The European species Apus cancriformis occurs in Algiers, but the
relations between the species of Northern Africa as a whole and those of
Southern Europe on the one hand, or of Central and Southern Africa on
the other, have yet to be worked out.
The soft-bodied Branchipodidae are not known in the fossil condition;
[25]
an Apus, closely related to the modern A. cancriformis, has been
found in the Trias, but the most numerous remains have been left, as
might be expected, by the hard-shelled Limnadiidae; carapaces, closely
resembling those of the modern Estheria, are known in beds of all ages
from the Devonian period to recent times; these carapaces are in several
cases associated with fossils of an apparently marine type. None of the
fossil species differ in any important characters from those now living, so
that the Phyllopoda have existed in practically their present form for an
enormously long period; this fact, and the evidence that species of
existing genera were at one time marine, explain the wide distribution of
animals at present restricted to a remarkably limited range of
environmental conditions.
Summary of the Characters of the Genera.
Sub-Order Phyllopoda.—Branchiopoda with an elongated body,

provided with at least ten pairs of post-cephalic limbs, the heart
extending through four or more thoracic segments, and having at
least four pairs of ostia.
Fam. 1. Branchipodidae.[26]—Carapace rudimentary, eyes stalked;
the second antennae flat and unjointed in the female, jointed and
prehensile in the male; female generative opening single; telson not
laterally compressed, bearing two flattened lobes, or none. The heart
extending through the thorax and the greater part of the abdomen.
A. Eleven pairs of praegenital ambulatory limbs.
a. Abdomen of six well-formed segments and a telson; anal
lobes well formed, their margins setose.
Branchinecta, Verrill—Second antennae of ♂ without
lateral appendages; ovisac of ♀ elongated. B. paludosa,
O. F. Müll.—Circumpolar.
Branchiopodopsis, G. O. Sars[27]—Second antennae of ♂ as
in Branchinecta; ovisac of ♀ short. B. hodgsoni, G. O.
Sars—Cape of Good Hope.
Branchipus, Schaeffer—Second antennae of ♂ with simple
internal filamentous appendage. B. stagnalis, Linn.—
Central Europe.
Streptocephalus, Baird—Second antennae of ♂ 3–jointed,
the last joint bifid; an external filamentous appendage. S.
torvicornis, Wagn., Poland.
Chirocephalus, Prévost—Second antennae of ♂ 3–jointed,
with a jointed internal appendage, which bears secondary
processes, four cylindrical and one lamellar. C.
diaphanus, Prévost (Fig. 2, p. 20).—Britain, Central
Europe.
b. Abdominal segments five or fewer, and a telson. Anal lobes
small or 0, sparsely or not at all setose.
Artemia, Leach—Second antennae of ♂ without
filamentous appendage, 2–jointed, the second joint
lamellar. A. salina, Linn.—Brine pools of the Palaearctic
region.
c. Hinder abdominal segments united with telson to form a fin;
anal lobes absent.
Thamnocephalus, Packard—Head with a branched median
process of unknown nature. Only species T. platyurus,
Packard—Kansas, U.S.A.
B. Nineteen pairs of praegenital ambulatory limbs.
Polyartemia, Fischer—Second antennae of ♂ forcipate;
ovisac of ♀ very short. Only species P. forcipata, Fisch.
Fam. 2. Apodidae.[28]—Carapace well developed as a depressed
shield, covering at least half the body. Eyes sessile, covered; no male
clasping organs; anal lobes long, jointed cirri.
Apus, Scopoli—Telson not produced backwards over the
anus; endites of first thoracic limb very long. A.
cancriformis, Schaeffer—Britain, Europe, Algiers, Tunis.
A. australiensis, Central Australia.
Lepidurus, Leach—Telson produced backwards to form a
plate above the anus; endites of first thoracic limb short.
L. productus, Bosc.—Central Europe. L. viridis, Southern
Australia, New Zealand, L. patagonicus, Bergh,
Argentines.
Fam. 3. Limnadiidae.—Body compressed; carapace in the form
of a bivalve shell, the two halves capable of adduction by means of a
strong transverse muscle; second antennae biramous, alike in both
sexes; in the male, the first or the first and second thoracic limbs
prehensile; telson laterally compressed.
A. Only the first thoracic limbs prehensile in the male; the carapace
spheroidal, without lines of growth; head not included within the
carapace-chamber.
Limnetis, Lovén—Compound eyes fused; anal spines
absent; ambulatory limbs 10–12. L. brachyura, O. F.
Müll (Fig. 3, p. 21).—Norway, Central Europe.
B. The first and second thoracic limbs prehensile in the male;
carapace distinctly bivalve, enclosing the head, with concentric
lines of growth round a more or less prominent umbo.
Eulimnadia, Packard—Carapace narrowly ovate, with few
(4–5) lines of growth. E. mauritani, Guérin—Mauritius.
E. texana, Packard—Texas, Kansas.
Limnadia, Brongniart—Carapace broadly ovate, with
numerous lines of growth, without distinct umbones; L.
lenticularis, Linn.—Northern and Central Europe.
Estheria, Rüppell—Carapace with well-marked umbones
and numerous lines of growth, oval; E. tetraceros,
Kryneki—Central Europe.

On Call Surgery On Call Series 4Th Edition Gregg A Adams MD Facs Full Chapter

Uploaded by

Copyright:

Available Formats

You might also like

On Call Surgery On Call Series 4Th Edition Gregg A Adams MD Facs Full Chapter

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

On Call Surgery On Call Series 4Th Edition Gregg A Adams MD Facs Full Chapter

Uploaded by

Copyright:

Available Formats

On Call Surgery: On Call Series 4th

Edition Gregg A. Adams Md Facs

Unlock your eBook today.

Place Peel Off

For technical assistance:

Other Titles in the ON CALL Series

GREGG A. ADAMS, MD, FACS

Clinical Associate Professor of Surgery

STEPHEN D. BRESNICK, MD, DDS

Copyright © 2020, Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any

Library of Congress Control Number: 2019935212

Content Strategist: Marybeth Thiel

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

3251 Riverport Lane

GR: To Corinne and Jack, for showing me what my true purpose is

Medicine changes daily and requires constant learning and curi-

We acknowledge all of our teachers, including our parents, instruc-

Most medical didactic education starts with a disease process,

MAJOR THREAT TO LIFE

SURGICAL CHART BIOPSY

Quick Look Test

Airway and Vital Signs

Selective History, Chart Review, and Physical

several systems, other aspects of the patient’s care, unrelated to

1 Approach to On-Call Surgical Problems 2

Why write a book on surgical on-call problems? All surgical train-

Major Threat to Life

MAJOR THREAT TO LIFE

In clinical practice, it is a wise educational tool to imagine what

Surgical Chart Biopsy

Quick Look Test

Selective History, Chart Review, and Physical

SPECIAL SURGICAL CONSIDERATIONS

Surgical patients are different from other patients in the hospi-

An important aspect of management of on-call problems is the

RESIDENT ON-CALL NOTE

Vital signs (VS): Temperature: 38.6˚ C

Urinary: No urinary catheter. Urine output is

Treatment: 1. Incentive spirometry every hour,

“Loading the Boat”

The practice of medicine has inherent risks. Exposure to blood-

TABLE 4.1 Universal Precautions to Prevent Transmission of

TABLE 4.1 Universal Precautions to Prevent Transmission of

TABLE 4.1 Universal Precautions to Prevent Transmission of

6. Is a nasogastric (NG) tube in place? Is it functioning normally?

MAJOR THREAT TO LIFE

RIGHT UPPER QUADRANT PAIN

RIGHT LOWER QUADRANT PAIN LEFT LOWER QUADRANT PAIN

FIG.5.1 Common etiologies of localized abdominal pain by

FIG. 5.2 Common etiologies of generalized abdominal pain.

Surgical Chart Biopsy

Airway and Vital Signs

from gentle shaking of the bed or the patient, or by percussion or

Selective History and Chart Review

Appendicular colic Renal colic

FIG. 5.3 Common cutaneous sites of referred pain by etiology.

1 Approach to On-Call Surgical Problems 2

TABLE 4.1 Universal Precautions to Prevent Transmission of

TABLE 4.1 Universal Precautions to Prevent Transmission of

TABLE 4.1 Universal Precautions to Prevent Transmission of

6. Is a nasogastric (NG) tube in place? Is it functioning normally?