CASES (17): THREE AA

We were wading through the afternoon office schedule, and things were going smoothly. We hadn’t had any calls from the hospital nurses about problems with any of our inpatients. I was enjoying the afternoon with our office patients. Most of them were older people, experienced in life, and often colorful. It was always a pleasure talking with them about their families, their work, and their grandchildren, even as I dealt with their diabetes, hypertension, heart failure, or whatever.

When I left one of the exam rooms where I had just seen one of our many COPD patients, I was dictating a note in his chart when Merdi came into my office. She was adding another case to the schedule. Someone that she thought might have an urgent problem.

She said, “It’s Mr. Bradford. He says he’s having some pain he’s worried about.”

I looked up from my paperwork and just nodded, “OK. Does he need us to call an ambulance?”

“No. He lives close to here and said he will drive over.”

The nurses had all been trained to treat all persistent abdominal and chest pain as an emergency.

*******

It wasn’t more than ten minutes later when the nurses had put Mr. Bradford into an exam room, and I was greeting him. He was already on the exam table. I looked at the nurse’s notes: pulse and pressure were higher than his usual.

“Hi, Mr. Bradford. Nice to see you. What’s going on?”

He got right to the point. “I started having this pain a couple hours ago. It’s in my lower belly and I feel it in my back too. I’ve never had this before.”

“Have you had a fall or any kind of injury that might explain your pain?”

“No. Nothing.”

I reached out to him, put my hand on his shoulder and said, “OK. Let’s have you lie back on the table.”

When he relaxed, I felt around his abdomen. It was soft and non-tender. It was normal, except, at about the level of his umbilicus, there was a very prominent pulsation which I could easily feel. I had not felt it anytime earlier when he was in for a periodic physical.

I knew he had high blood pressure and had been a smoker. I stood back from the table, and when he had sat up, I told him, “Mr. Bradford, with your belly pain and back pain, and with what I feel in your abdomen, I think you have an expanding abdominal aortic aneurysm. Merdi will call the hospital and arrange for you to have a stat abdominal ultrasound. If that confirms what I think, we’ll have you get an emergency CT scan of your abdomen. I’m certain enough of the diagnosis, just from physical examination, that I want to go ahead and arrange for the surgeon on call to see you there.”

He looked surprised and said, “Well. OK. If you think it’s necessary.”

“I do think it’s an emergency. I think you’re going to have surgery this evening. I think you should go to the hospital by ambulance.”

“No. My wife is here with me. We can be there in ten minutes.”

Within the hour, Merdi came to me and told me the tests were positive for a six-centimeter aneurysm. It hadn’t yet ruptured. The surgeon saw him. Mr. Bradford was going to emergency surgery.

*******

I had seen a couple more patients and was getting near the end of the afternoon’s schedule when Merdi came to me again.

She said, “Mr. Ridgeway called. He says he’s suddenly having back pain that won’t quit. I told him to come in. He’ll be here shortly.”

He was there in just a short while. Merdi was watching for him and put him into an exam room straightaway. I was free then and went in to see him.

“Hi, Mr. Ridgeway. Are you having some pain today?”

“Ya. It just came out of the blue. It hurts in my lower back.”

He pointed to his lower abdomen, “And I feel some pain here.”

I examined him carefully, and when I was done, I could hardly believe what I was saying when I told him, “You have an abdominal aortic aneurysm that is causing your pain. This is very dangerous. We need to get you to the hospital right away.”

He had the same workup at the hospital that Mr. Bradford had. And the same surgical consultation. They both had surgery that evening.

The experience made me reflect on the suddenness with which an aneurysm can appear. My experience that day was hard to believe. It had never happened to me that, in one afternoon I had two patients walk in with signs and symptoms of rupturing aneurysms.

*******

That afternoon, when Merdi told me we were done for the day, I leaned back in my chair and thought about the afternoon’s experience. It brought to mind an experience I had had a few years prior when I was a resident in training. My memory was of one late night when I was totally worn out from a long day’s work and was called to the emergency room to admit a new patient that was having chest pain. When I got there, ER staff doctor told me the man might be having a heart attack, a myocardial infarction.

But when I went into an exam room and greeted the patient, a different picture emerged. He was a healthy appearing man of about sixty years, still fully dressed, lying on a gurney, partly propped up. He had blond, curly hair. He wore glasses. His face was contorted in pain. He was gripping his right hand over his heart. When I asked him where he was hurting, he gasped in pain and told me, “Right here in my chest. And in my back. It hurts really bad between my shoulder blades.

I wasn’t with the man for very long. We didn’t talk anymore; he was in too much pain. After I examined him, I went back out to the nurses’ station to look at the EKG and portable chest x-ray the ER doctor had done. The EKG didn’t look like a heart attack to me. When I looked at the portable chest x-ray with the ER doc, I saw something that I had learned about from Dr. Benjamin Felson in medical school. There was an extra little bump, a “mogul” on the left side of the patient’s heart.

I said, “Look. That’s abnormal. I think it’s an ascending aortic aneurysm. That’s consistent with his pain.”

The ER doc was quizzical and replied, “Where? I don’t see it.”

I said, “No, that’s abnormal. We need to get him an emergency chest CT and an emergency vascular surgical consult.”

The ER doc said, “OK. I’ll get that lined up as soon as possible.”

I went back up to the ICU to finish my work there. In about a half hour, the ER doc called me. He said the patient had died on the gurney on the way to Xray. He told me the family had given permission for an autopsy. He said I could go down to the morgue to see it.

I went down to the morgue where the pathologist had already opened the chest. When I walked in, the patient was naked, lying dead on the table. The pathologist looked up from the open, bloody chest and called me over. He simply said, “The ER doc told me you diagnosed an aneurysm.”

With a shiny metal probe, he pointed to a spot on the aorta and said, “Look at this. Ruptured thoracic aortic aneurysm. You were right. Good call.”

I thanked him and left the room. I wasn’t pleased. I wasn’t sad. I was so tired. I felt nothing.

*******

While I sat there in my office, I thought about the man with the thoracic aneurysm and how I felt that night. I reflected on the way medical training, in time, teaches one to have just the right amount of empathy for the sick and injured. Just the right amount caring so we can still be objective and take the best care of them. I saw both Mr. Bradford and Mr. Ridgeway next morning when I made hospital rounds. They were both doing well. They recovered and left the hospital in good condition with their new aortic grafts.