Falling Leaves Assisted Living — abd pain

Location: Charlie post

Time: 11:30 Wednesday

Conditions: Misty and cool

Equipmentfully stocked



Yawn. Yawn. Yaaaawn.

You’re about to yawn for probably the tenth time in ten minutes — and Steve looks ready to strangle you — when the radio crackles… (click for audio)

[Ambulance 61, start priority 3 to 310 Homer Rd, the Falling Leaves Assisted Living, for a 53-year-old male with abdominal pain. That’s a cold response for the A 6-1, 310 Homer Rd  on the fifth floor, for the abd pain. Between Browning and Appleton. Fire not responding. Time out 11:31. 61?]

Click to expand



Seems like it’s been a while since you had an abdominal pain. What a tragedy.

Steve rolls you toward Falling Leaves with truculent inertia, and within fifteen minutes you’re pulling up. You toss the airway and first-in bags atop the stretcher and head for the elevator.

As you pass the front desk, the receptionist hands you a stack of papers with basic info. “511. The nurse will meet you up there,” she says. In fact, it will probably be an LPN or similar — indeed, the official Scenarioville dispatch policy is that assisted living centers are not skilled care facilities and therefore cannot actually request a low-priority ambulance response. For whatever reason, that didn’t apply today. Nobody ever accused your dispatchers of consistency.

As you ride the elevator up, you flip through the papers, reading:

Clarence Pimento


CURRENT ISSUES: macular degeneration; PVD; h/o alcohol; vertigo; Hep B


ALLERGIES: shellfish


“N… none? What kind of Hep B 53-year-old isn’t on any medication?” you wonder.

“Maybe he found a cure,” Steve grumbles as he brushes lint off his sweater.

On the 5th floor, you wander the halls until you find 511. Knock knock knock on the door, and a voice beckons you in.



It’s a nice looking room, pretty typical for an assisted living. Inside, a nurse-looking lady waves you toward an elderly fellow in an easy chair. “Hi guys,” she greets you cheerfully. “Stomach’s been hurting for a while now.”

Trotting over, she calls, “Clarence! The ambulance is here!”


Initial Assessment

Kneeling beside the good Mr. Pimento, you find a reasonably well-appearing male, appearing rather older than his stated age and in no profound distress. He’s breathing easily, and as you take his wrist, you find lukewarm, dry skin with a moderately strong and regular radial pulse at an unremarkable rate.

“Mr. Pimento?” you ask.

“Hello,” he replies, meeting your glance.

“I’m Sam. How’re you feeling?”

“My stomach hurts,” he replies.





“How long’s it been hurting?” you ask.

“Since last week.”

“Can you point to where it hurts?”

He indicates a diffuse area in the upper abdomen, somewhat focused on the left side.

“Right there? Is it moving anywhere else?”


You catch Steve’s eye. “Vitals?” He swoops in on the other arm with a BP cuff.

“What sort of pain is it? Can you describe it for me?”

“Uh… it’s just… it hurts. It’s been coming and going.”

“Have you noticed anything in particular that makes it better or worse?”

“No, it’s just been getting worse.”

“Okay. Did the pain start all of a sudden, or did you just gradually begin to notice it?”

“I guess I noticed it first one morning, but it wasn’t too bad; it got worse since then.”

“Have you been feeling nauseous at all? Like you want to throw up?”


“Have you actually thrown up?”

“I did today.”

“That’s when we called,” the nurse tells you.

“What did you bring up?”

“Just some bile.”

“Any blood or black stuff in there?”


Pulling up his shirt a bit — “Mind if I take a look?” — you expose his abdomen. There is modest adipose tissue, but no visible lesions or obvious distention. You gently palpate, touching the painful area last, and eliciting a grunt of pain there.

“That hurts?”


There is perhaps a bit of guarding, but no gross rigidity, and no tenderness elsewhere.

“Have you been eating and drinking?”

“A little.”

Behind him, the nurse is shaking her head. “Almost nothing since two days ago. He says he can’t eat.”

Busted. “Have you been moving your bowels?”

“Not so much since I stopped eating.”

Well, that follows. Conservation of mass and all that.

“Any trouble urinating?”

“Nothing new.”

Steve flicks you a card with these vitals:


HR 98

RR 16

“How’s your breathing, Mr. Pimento?”


“How’s your chest feel?”


“Been feeling any fever or chills?”


“Anything else been bothering you aside from that pain there and the nausea?”


“Which hospital do you usually visit?”

“St. Vincent.”

Steve is bustling around, retrieving the stretcher and dropping it down.





“All right; what do you think? Shall we bring you over there and they can check you out?”

“Okay. It really hurts.”

“I’ll bet. Okay to stand and walk over to here?”

You take both his hands and assist him out of the chair. He seems slow but fairly steady on his feet, and walks over to the stretcher as you follow, ready to catch him but (it turns out) needlessly. He sits, and immediately asks to sit up; you elevate the back bolt upright, and even then he leans forward a little.

As you buckle him up, you ask, “Are you taking any medications?”

“No drugs!” he exclaims with vigor. “No booze, no drugs, no poisons. I drank for sixteen years and nine months; I been sober now for two years, one month, three days. The docs are always trying to push drugs on me, like dealers, like they work for the government. I tell ’em to shove it up their keister.”

The nurse is trying not to giggle. “Fair enough. Have you ever had pain like this before?”

“Yes. I had pancreatitis.”

Ah. “When?”

“A few times.”

“When was the most recent?”

“Oh… year ago.”

“So this feels similar to that?”

“Exactly the same.”

“Okay, on a scale of 1 to 10, if 10 is the worst you’ve ever had this sort of pain, how bad is it right now?”


“So this is the worst you’ve ever had it?”


You’ve reached the ground floor. “Have you ever had any problems with your gallbladder or your liver?”


You load him up and hop onto the seat. Steve shuts you in and jumps up front. “St. V’s. We’re all set,” you call up to him.

“How do you want it?”

In your book, pain is a perfectly good reason to go fast rather than slow. Of course, dying in a fiery wreck won’t help anybody, but Steve is one of the few drivers you trust to get you there safely. “Take an easy 2,” you tell him, meaning with lights and sirens but no drama.

As you start rolling, you pop over and grab the radio. Hailing St. Vincent’s, you deliver this notification… (click for audio)

[Morning St. V’s, Scenarioville Ambulance 61. We’re six minutes out with a 53-year-old male, coming from an assisted living, complaining of 11/10 diffuse upper abdominal pain worsening over the past week, tender, non-rigid; some nausea and vomiting as well. History of pancreatitis. Vitals stable, doing okay. Any questions?]

“Negative, we’ll be awaiting your arrival.”

You spend the rest of the trip chatting with Mr. Pimento about how his body is a temple.

Rolling up, the charge nurse points you into — “Bed 14” — and you match up the beds and slide him over. Another nurse saunters in, and you give her this quick report (click for audio):

[Well hello there… this is Clarence Pimento. He’s 53, lives at the Fallen Leaves Assisted Living. Last week he had a sort of insidious onset of diffuse upper abdominal pain which is tender, non-radiating, a little worse on the left, and getting worse. He’s been nauseous as well, vomited for the first time today, no blood. He does have a history of alcoholism and pancreatitis, last flare-up was last year, and this feels very similar, but worse than he’s had before. Hep B as well. Doing okay otherwise. Takes no meds and doesn’t want any.]

She thanks you absent-mindedly, seemingly perturbed by that last part. Eager to get back to your nap, you find Mr. Pimento a warm blanket, shake his hand, and wish him luck.

Back in the truck, Steve is in the driver’s seat, looking bemused. “Maybe I should rid my body of poisons too, huh?”

“There wouldn’t be anything left, you son of a bitch.”



Diagnosis: chronic pancreatitis

The pancreas is an undersung but important organ. Better known for producing insulin, it also plays a highly necessary role in digestion, secreting pancreatic juices into the intestines which help break down proteins.

Pancreatitis is essentially inflammation of the pancreas. It occurs for various reasons, but generally some kind of obstruction blocks the flow of the digestive enzymes through their ducts; they back up into the pancreas and start to digest the organ itself, causing pain and damage. The most common cause is long-term alcohol abuse.

It classically presents with a severe, ongoing upper abdominal pain that may be focused on the left and radiate to the back. You’ll often find these people sobbing in pain, and seated upright, leaning forward, or cribbed on their side — trying to take pressure off the organ, which helps alleviate the pain. Nausea is common and fever can occur. Lab tests and imaging will help confirm the diagnosis, and these folks will usually be admitted for at least a few days while they’re medically managed. Generally they do okay, but poor outcomes are certainly seen, and these attacks tend to recur.

Mr. Pimento may prove difficult to treat, and generally have a poor long-term outcome from his chronic problems, due to his refusal of medication.

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