There is something called a “sense of impending doom” in medicine. It is a symptom that patients describe that is distinguishable from a panic attack. Sometimes as a health care provider, you just get the vibe that something very bad is going on. In any case, when this is present, you pull out all the stops to figure out what is going on. The other night we had one like this. A 75 year old woman who came in by EMS essentially either having a life-threatening event, or was purely psychiatricly deranged. She was basically complaining of severe pain all over (often meaning one is in need of Vitamins H or A) – but after a few mg of Morphine, she calmed down enough for us to realise she was not crazy. She seemed like she was normally stoic and had no diagnosed medical problems (although she smoked like a chimney so she probably had some COPD (emphysema)). She complained now particularly of severe chest pain but had a normal EKG. Her blood pressure was elevated and she really looked uncomfortable. – in that sort of “OMG this patient has something really bad going on!” way. She got a chest x-ray which showed something very ominous. Her mediastinum was VERY abnormal appearing. It was widened, which although x-rays are notorious inaccurate in diagnosing, in this case it was very apparent. This was proven even more by comparing a x-ray she had only three weeks prior in the hospital – the mediastinum was very different now.
She was sent for a CT scan to rule out an aortic dissection even though she never complained of specific back pain (often the case with dissections). Unfortunately, she shortly started to go south in the CT scanner. The RN called saying she could not get the scan since she was sitting bolt upright, flailing her arms and refusing to lie down, complaining of severe pain and kept saying she was “going to die”. Her blood pressure was now only 110 – and she had not even received any anti-hypertensive medications. She was also now tachycardic to 120. So, she was brought back to the ER and was given fluid and some more morphine – but now it was apparent she was decompensating. Her mental status began to go – so the Cardio-thorasic surgeon was called even without a CT scan because the suspicion of dissection was so high. Fortunately, a relatively non-grumpy surgeon was on and stated he would be in in about 30 minutes. So, she was intubated uneventfully but now a repeat CXR showed MASSIVE enlargement of the aortic root – much worse than the one only about an hour or so prior. Her blood pressure continued to drop – but was rushed back to CT to get the study. What is showed was horrific. Indeed she had an aortic dissection (and ascending one) but also had a partial rupture of an aneurysmal segment with a large expanding haematoma. This was crushing the superior vena cava (SVC – the large vein that brings blood back to the heart from above) causing the severe impedance of blood flow back to the heart. The lungs were filling with blood and now her blood pressure was 60 systolic. Just about now the CT surgeon arrived and everyone was trying to stabilise the patient for the OR. She was on maxed out Levophed and Dopamine (drugs to raise the blood pressure), fluids, and a blood transfusion – and with that had a systolic BP of 50! Finally, despite her unstable condition, she went to the OR – he son was told she had about a 5% chance of survival.
A phone call to the OR about three hours later told us that the patient was still alive (amazingly) and was still being worked on. She wound up getting her entire aorta replaced down to her renal arteries! 8 hours in the OR!
Even more amazingly she is still alive three days later. However, the prognosis is still very bad since now it looks like the blood flow that was lost to her GI tract during the event and surgery has caused the bowel to be in jeopardy(mesenteric ischaemia). She is now septic from that and her chances of survival are even less than 5%. She will likely have to be re-operated on so we shall see.
There is nothing worse than a patient who has that look of impending doom in their eyes. We have to learn to recognise it and act on it fast.
This is how John Ritter died. RIP – I grew up watching Jack Tripper in Three’s Company and thought he was brilliant!