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Lions and Tigers and Bears

Lions and Tigers and Bears

Imminently Croakable

Swisher, Loice MD

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doi: 10.1097/01.EEM.0000462412.87166.36
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    Coming out of a patient's room, my eyes immediately fell on a hallway bed on which a sobbing linebacker-sized 26-year-old man rocked back and forth in a fetal position. He looked sort of like “a kidney stone,” but the tech handed me an EKG chirping “chest pain.” The EMR indicated he had a past medical history of asthma, hypertension, and congestive heart failure, but he didn't take any medications. He smoked but denied drug use.

    The EKG was not normal. There was no worrisome ST segment elevation, but left ventricular hypertrophy with diffuse T wave repolarization abnormalities suggested longstanding poorly controlled hypertension. He was worried the pain was cardiac because he had a “big heart.” The left-sided chest pain traveled to his back, and he felt short of breath. His exam was normal except for his blood pressure: 158/98 mm Hg.

    Within minutes of receiving IV morphine, he was lying on his back texting and joking with friends. Annoyance was palpable in the nursing station: Nothing is wrong with you if you can text.

    I wasn't going to be led down that path this time. I have taken that awful, shocking journey, pronouncing patients who are too young to have whatever. OK, maybe not 26, but it was the right story. My mantra to protect myself and my patient is “always maintain a high index of suspicion.” He was going to have to prove to me he was well, not prove to me he was sick. The chest x-ray provided no reassurance. (Image 1.)

    He not only had a widened mediastinum but a double density at the aortic knob. The CT angiogram confirmed the double density of a true and false lumen of this type A dissection. (Image 2.)

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    mage 2.

    Tip to remember: Doctors suspect aortic dissection in less than half of all cases. You must maintain a high index of suspicion and learn the subtle signs to save your imminently croakable patients. (Suggested reading: Oman Med J 2008;23[2]:112; http://bit.ly/1oHwqPj.)

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