I had a weird shift, with a
strange predominance of chest pain patients. Nothing unusual about that
per se, but they were strange chest pain patients. The median age was
28, and all of them had very atypical symptoms -- sharp pain, pleuritic
pain, burning pain, pain associated with itching, pain associated with
half the body going numb, pain associated with a sudden urge to go
shopping, you get the drift.
So, what can you do? I did the drill and worked them all up appropriately. Every once in a while I would shake my head at the 28-year-old who had a (negative) troponin on the chart. (But doctor, the protocols say everybody above 25 gets a troponin and coags and...) So I thanked the nurses for following the protocols and sent all the chest painers home, except for a couple who had enough risk factors to buy themselves a rule-out.
One of the last chest painers I saw was a middle-aged guy, totally healthy, with atypical pain and a lot of anxiety. His pain was sternal, and worse when I touched it, and he was hyperventilating. I probably was going to admit him for a rule-out based on age alone, but I had no expectation that he would have real pathology as the cause for his pain. Just one more pointless expenditure of time and money to reassure the perfectly healthy. So he got the full battery of tests and some morphine (which did nothing) and some ativan (thank you very much, doctor, I feel better now).
I pride myself on reading all my own x-rays and ct scans, even though we have excellent local teleradiologists. I enjoy it, it's a bit faster in most cases than waiting for the read, and it's good practice. So as I was getting the admitting packet together, I took a look at the patient's chest x-ray.
The radiologist had commented on a tortuous aorta, but to me it just didn't look right. My (overactive?) imagination thought the whole aorta looked plump. The red arrows make it look more obvious, since the right heart border and the aortic margin are sort of superimposed. It wasn't a particularly striking CXR without the "hey dummy" arrows in place. I asked the rad what he thought, and got the standard "well, could be, but it's hard to say, if you are concerned, get a CT." I double checked the blood pressures -- symmetric, and re-interviewed the patient to verify that the pain was not tearing or radiating to his back. Well, I thought, why not? I've chased wild geese for less in the past, so I ordered the CT. The study was done gratifyingly quickly for so late in the shift, and I lazily scrolled through the images before the patient was even back in the department. this is what I saw:
At the level of the aortic arch.
A bit below that level.
This is where I got my jolt of adrenaline. No way was I expecting this to be the real deal. It went all the way down to the iliac arteries. For the non-medical types reading, this is an , in which a small tear in the lining of the aorta allows the blood to separate the layers of the aorta and create a "false lumen" or a separate compartment within the aorta. The shearing forces of the pulse cause the separation to propagate on down the aorta. This can cause all sorts of complications, from clotting off important arteries (coronary, carotid, renal, vertebral) to simply rupturing and causing death (which is what ). The red arrows on the CT scan show (so clearly and beautifully) the initimal flap and false lumen, and the aorta in the lower image is quite distended indeed -- probably not far from the rupture point.
The classic presentation in this case was simply absent -- the characteristic pain and physical findings were not present. The CXR is notoriously non-specific: in most cases of dissections, the CXR is abnormal, but rarely in a specific way to point a practitioner toward a dissection. It was pure luck that I had taken a look at the x-ray myself and given it some thought. I wiped my brow as the cardiothoracic surgeon and her team wheeled the patient off to the OR, as this would have been an easy diagnosis to miss (at least initially) and the consequences would have been lethal.
The only take-home point that I can think of here (other than to read your own films and be suspicious) is that I have now diagnosed about a half-dozen dissections in my career, and the one thing they have all had in common is that they were all very anxious. Some were pretty classic, some were not, but all of them had that "something's not right" fear written on their faces. It's a pity that anxiety is sensitive but not specific for dissection, as all of my chest painers were anxious that night.
Another bullet dodged. I love this job.
So, what can you do? I did the drill and worked them all up appropriately. Every once in a while I would shake my head at the 28-year-old who had a (negative) troponin on the chart. (But doctor, the protocols say everybody above 25 gets a troponin and coags and...) So I thanked the nurses for following the protocols and sent all the chest painers home, except for a couple who had enough risk factors to buy themselves a rule-out.
One of the last chest painers I saw was a middle-aged guy, totally healthy, with atypical pain and a lot of anxiety. His pain was sternal, and worse when I touched it, and he was hyperventilating. I probably was going to admit him for a rule-out based on age alone, but I had no expectation that he would have real pathology as the cause for his pain. Just one more pointless expenditure of time and money to reassure the perfectly healthy. So he got the full battery of tests and some morphine (which did nothing) and some ativan (thank you very much, doctor, I feel better now).
I pride myself on reading all my own x-rays and ct scans, even though we have excellent local teleradiologists. I enjoy it, it's a bit faster in most cases than waiting for the read, and it's good practice. So as I was getting the admitting packet together, I took a look at the patient's chest x-ray.
The radiologist had commented on a tortuous aorta, but to me it just didn't look right. My (overactive?) imagination thought the whole aorta looked plump. The red arrows make it look more obvious, since the right heart border and the aortic margin are sort of superimposed. It wasn't a particularly striking CXR without the "hey dummy" arrows in place. I asked the rad what he thought, and got the standard "well, could be, but it's hard to say, if you are concerned, get a CT." I double checked the blood pressures -- symmetric, and re-interviewed the patient to verify that the pain was not tearing or radiating to his back. Well, I thought, why not? I've chased wild geese for less in the past, so I ordered the CT. The study was done gratifyingly quickly for so late in the shift, and I lazily scrolled through the images before the patient was even back in the department. this is what I saw:
At the level of the aortic arch.
A bit below that level.
This is where I got my jolt of adrenaline. No way was I expecting this to be the real deal. It went all the way down to the iliac arteries. For the non-medical types reading, this is an , in which a small tear in the lining of the aorta allows the blood to separate the layers of the aorta and create a "false lumen" or a separate compartment within the aorta. The shearing forces of the pulse cause the separation to propagate on down the aorta. This can cause all sorts of complications, from clotting off important arteries (coronary, carotid, renal, vertebral) to simply rupturing and causing death (which is what ). The red arrows on the CT scan show (so clearly and beautifully) the initimal flap and false lumen, and the aorta in the lower image is quite distended indeed -- probably not far from the rupture point.
The classic presentation in this case was simply absent -- the characteristic pain and physical findings were not present. The CXR is notoriously non-specific: in most cases of dissections, the CXR is abnormal, but rarely in a specific way to point a practitioner toward a dissection. It was pure luck that I had taken a look at the x-ray myself and given it some thought. I wiped my brow as the cardiothoracic surgeon and her team wheeled the patient off to the OR, as this would have been an easy diagnosis to miss (at least initially) and the consequences would have been lethal.
The only take-home point that I can think of here (other than to read your own films and be suspicious) is that I have now diagnosed about a half-dozen dissections in my career, and the one thing they have all had in common is that they were all very anxious. Some were pretty classic, some were not, but all of them had that "something's not right" fear written on their faces. It's a pity that anxiety is sensitive but not specific for dissection, as all of my chest painers were anxious that night.
Another bullet dodged. I love this job.