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Emergency Medicine News:
doi: 10.1097/01.EEM.0000403710.71918.f6
Diagnosis Deconstructed

Diagnosis Deconstructed: An African Tribe and the Most Vital of Signs

Morchi, Ravi MD

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The Masai are a tribe in Sub-Saharan Africa that lives today much as they have for hundreds of years. They wear brightly colored beads and garments, tend to their crops, hunt and gather at times, and occupy cramped cow-dung huts with their six children. They are the toughest people I have ever had the opportunity to care for. Even by rural African standards, other tribes know the Masai as stoic. An old Masai tradition was to have young boys transition into adulthood only after they killed a lion. If they failed to kill a lion, they literally didn't become a man.

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The government of Kenya put a stop to this activity, not because they were running out of Masai, but because they were running out of lions. The gem of the tourist safari excursion, lions became hard to come by. In fact, if you are on safari in east Africa and see a Masai strolling along with his spear and his bright red robe, you should know that there are no lions in the vicinity. They smell and fear the Masai. Better head the other direction if you want to catch a glimpse of the gems.

So when a Masai finds his way to your hospital, your senses should be heightened.

The United States. It was a bright morning, and a middle-aged man had driven himself to the ED. He claimed to have intermittent chest pain, so he was triaged immediately into a bed. His ECG was unremarkable.

My first thought, he sure is dressed oddly for a workday. A portly man with checkered, brightly colored pants, funny shoes, and a hat. I introduce myself.

“What brings you here?”

“Oh, it's nothing. I think I overreacted.”

“To what?”

“I was having this pain in my chest. But it's gone now. It only lasted a few seconds. I think it was nothing. Maybe indigestion.”

“Just once?”

“Well, a couple of times on and off. But only a short time each. And it's gone now. I feel fine. I think I overreacted.”

Short, fleeting episodes like this did not sound like cardiac ischemia to me. It turns out the episodes occurred randomly, without exertion or any clear exacerbating or alleviating factor. They would appear and then disappear just as abruptly. Central chest and sometimes to his neck, he has never had these symptoms before.

“How would you describe the pain?”

“Sharp. But it's gone now, doctor. I think I overreacted.”

Yes, you mentioned that already, I thought. And he would say that again before the day was done. No other associated symptoms. Review of systems was flat, and he was feeling fine just moments before the pain started. At the age of 60, he carried no medical history and no medications.

“Do you see a doctor regularly?”

“No, I'm in good health.”

Not sure I can put much weight on the absence of medical history in someone who relies on self-diagnosis.

“Do you exercise? Do you ever get any symptoms with exercise?”

“I exercise every morning. I play golf. And I never have any problems.”

Ah. The apparel makes more sense.

His heart rate was 70 bpm, his blood pressure was 150/90 mm Hg, his respirations were 14 bpm, 98% on room air, and he was afebrile. His vitals were unremarkable other than what may be white-coat hypertension. The remainder of his physical exam was normal.

“Can I go home? Everything is better now, and I want to get back to the course. I think I overreacted.”

He was decidedly unexciting as a patient. Everything about him looked benign. A peculiar history but no objective abnormalities. A retiree intent on being discharged. In his and my mind alike, he had one foot out the door. Ready to go home? He looked it. Why keep him any longer? He decided to bring himself here; I suppose he could decide to take himself out.

And that's when I overheard someone say it.

“It's gorgeous outside,” exclaimed a medic strolling in from the ambulance bay. By all bedside measures, the severity of our patient's chest pain was trivial, fleeting, and now gone. Per clinical assessment, it was not a factor. But I realized after our medic rolled by, that there is another measure of severity to this man's former chief complaint. And that measure was not at the bedside. I had to sense it myself.

I walked out the ambulance bay into the lot. It was beautiful. Maybe mid-70s with clear blue skies and only a small handful of clouds. And the absence of something … wind. No wind.

Inconsistency. However feeble the chest pain appeared by our patient's words and his body's manifestation, according to the weather, it had to be stronger. I believed the weather because I felt it. The pain was strong enough to tear an avid golfer away from the golf course on a day like this. Not just any day, a day with perfect skies and no wind. One where he could be sure to score well.

This man was Masai. He did not wear brightly colored beads, and I was pretty certain he could not kill a lion with a spear. But a Masai nonetheless. He had every reason not to be in the hospital. It wasn't in his Masai culture; it wasn't in his typical Masai habit, not on a day like this. Everything outside the ED said he should be on the golf course. But he wasn't. Although the standard vitals drawn were nothing to mention, his principal vital sign was abnormal. The most important one: He was here. His carbon skeletons sat inside this ED, right before my eyes. This most vital of signs had to be explained.

His minimizing his symptoms did not matter. His benign physical exam did not matter. To gauge what he really had required questions not normally part of a medical inquisition.

“So what is your handicap?”

“Twelve.”

Is that good? Not sure why I asked that question. Did not know what to do with the answer. I asked our nurse. He wasn't sure what to make of twelve either. Maybe it is my segue to more.

“How often do you golf?”

“Every morning. Eighteen holes usually.”

This is not good, I whisper to myself.

“And at what hole did the pain start?”

“The third.”

“And at what hole did you stop and decide to come to bring yourself here?”

“Fourth.”

Uh, oh. This is getting worse. Whatever the stimulus, it was strong enough to rip this man off the course in just one hole. He could navigate only one hole on a perfect, windless day before leaving his passion on the grass. Just one more gauge for severity.

“When was the last time you left the golf course early?”

“Well, I can't recall. Maybe one time. I mean, for my daughters' wedding.”

Oh, no. This history just went from bad to horrible. This had to be some kind of pain. Ten out of ten pain. The saddest of the sad faces on the pain scale. His golf card said so.

I know of two things that produce this kind of pain, the one-hole-only kind of pain. The kind of pain as persuasive as tens of thousands of dollars spent and his beloved daughter beckoning him to her special day.

Esophageal perforation or aortic dissection.

“How does it feel when you swallow? Is there pain?”

“It feels a little funny. No pain, I mean, just a little odd to swallow. I think it is heartburn. Maybe indigestion. But nothing, doctor, nothing bothering me much.”

No true odynophagia. No subcutaneous air on palpation of his neck. No Hamman's crunch on auscultation. This is not spontaneous esophageal perforation.

His CT angiogram showed it. Aortic dissection, type A. The flap producing pseudoaneurysmal dilation of the false lumen within the aortic arch, indenting the neighboring esophagus and producing a “funny” feeling when swallowing. The flap had not progressed to his posterior descending thoracic aorta, so no radiation of pain to his back. Not yet at least.

The Masai come in all shapes and colors. Particular to different emergency departments and different communities, they can be easy or difficult to spot. But when they come to the hospital with their peculiar, brightly colored garments and single abnormal vital sign, our senses must be heightened.

Comments about this article? Write to EMN at emn@lww.com.

Dr. Morchi is the di...
Dr. Morchi is the di...
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