One More Notch. By Thomas A. Naegele, DO. Las Vegas, 2:37 am Saturday Night

Transcription

1 One More Notch By Thomas A. Naegele, DO Las Vegas, 2:37 am Saturday Night For a saturday night, it has been okay. A 24 hour shift with some rest is the whole idea. In most rural Emergency Departments (ED), 24 hour shifts are fine. For years, most patients have been appropriate and even though an ED may average 30 patients per 24 hours, by eleven pm, it becomes very slow, even empty and it typically stays that way until the next morning. In the recent years, we have seen some changes that may eliminate the 24 hour shift in the rural EDs. The entitlement programs with social worker input have encouraged the use of Emergency Departments for any medical problem or question or even to refill acetaminophen (called paracetamol in most of the world) because the welfare programs will pay for tylenol if the medicaid recipient has a prescription for it.. As a result, patients with health care problems that have been going on for a few days, a week, a month and sometimes longer come to the ED at all hours of the night because of the convenience, many a patient has told me that they came to the emergency department at 3 am because the bars were closed and since this problem had been bothering them for months, they figured 3 am would be a good time for quick in and out care. Should the entitlement programs develop a methodology for penalizing inappropriate use of the emergency department, now this would be an interesting twist. As the majority of rural EDs clientele are on entitlement programs, we cannot alter this course of action as this is our bread and butter. Enough, I ll step down from the soap box. Around 11 pm, the ambulance brought in a 20 y/o college student that was in a single vehicle accident. They were up on the mountain road and drove off the cliff. Spacial calculus can be a problem with an inexperienced driver under the influence of ethanol. The patient was in severe distress with blunt abdominal

2 trauma suspicious of a spleenic rupture which was in turn confirmed by CT scan and by immediate life saving surgery. In elaborating the story, the paramedics reported that the vehicle had veered off the road and went over the embankment and ended up going down the steep mountain side more than 100 feet down eventually getting stopped by the rocks and trees. The car was totaled, never to be driven again. Dr Rubio, the general surgeon on call, was called in, and performed the surgery in the nick of time. Dr Carlos Rubio just got through with the case and was on his way back home, when another patient came into the ED complaining of chest pain. He was a 20 y/o college student from Highlands University. He was brought in by some of the other college students living at the dorm. During the examination, with some encouragement, the story started to unveil. Mark, the 20 y/o college student, was in the car with Phil, the college student that came in by ambulance from the MVA and was taken to the operating Room (OR) for spleenic fracture repair. Mark left the scene of the accident because he was drunk and did not want his license taken away. (In New Mexico, if the driver of the car is drunk, then anyone in the car with a valid drivers license also gets their license revoked.) He walked 4 miles back to the dorm complaining of chest pain all the way. He accounted it to his seat belt. But falling down a 100 foot cliff can also give one a good reason for chest pain. On his walk back, he called 911 and reported the accident, but did not leave his name. Now, just after 2:30 am, his chest pain was still there and instead of getting better it was getting worse. Physical exam revealed Head: Normocephalic, scalp hematoma, Eyes: pupils reactive and equal, extra ocular muscle fully functional, Ears: canals clear, TMs with COL and no blood, Nose: no CSF, no abnormalities, Mouth-Throat: moist, tongue midline, no facial droop, neck supple. Chest: Heart had a regular rate, no murmurs. Lungs were clear in all fields. Abdomen: had tenderness

3 with intermittent guarding in the left upper quadrant and the umbilical area, Groin: no abnormalities. Upper Extremities: numerous small abrasions, pulses strong and symmetric, motor function symmetrical and complete. Lower Extremities, numerous abrasions, pulses strong and symmetric, motor and sensory intact. The chest pain was not reproducible by palpation and it was very curious. EKG revealed a normal sinus rhythm. Chest x-ray, gave me the impression of a widened mediastinum. And as the surgeon was just walking by, I requested a consult on this unusual presentation of traumatic chest pain. Dr Rubio, agreed, the mediastinum did not look quite right, so we ordered a CT Scan of the chest (as we have to call in the technician and warm up the machine this takes at least one hour before the machine is even ready for the patient). In the meantime, the abdomen demonstrated intermittent rebound tenderness, so we went ahead and performed a peritoneal lavage. The peritoneal lavage came back with a higher than usual red blood cell count, but not that much higher, leaving the question of was there abdominal bleeding? Unanswered. Or was it the result of nicking a blood vessel during the procedure of putting the tube into the peritoneal cavity? As this can give a false positive. Still unsure. In CT, everything looked normal. But again the descending aorta looked liked it had a small notch in it, but it was not clean and clear, it was something that could be a typical artifact (an error from the device giving a reading that appears pathologic, but in reality is not) or an anatomical variant. Dr Rubio and I puzzled over it. With a non-confirmatory peritoneal lavage, and this unrelenting chest pain, we decided to admit the patient for observation. IV Morphine was giving Mark some relief but the pain was still there and the

4 source was still not clear. Pain not relieved by narcotics is an ominous sign. In the morning, we repeated the chest CT. The descending aorta, still had the notch, it had not progressed and it had not changed. The pain was still unrelenting with morphine giving relief but again not completely obliterating it. In discussion with the surgeon, we were both thinking of an aortic dissection. We needed a vascular study to confirm this however as in most small rural hospitals, this diagnostic study was unavailable. So we transferred the patient to a larger hospital in Albuquerque. With copies of the x-rays and CT, we discussed the case over the phone with the receiving vascular surgeon. He too was concern, as he had cared for this problem a number of times, and the story matched the potential pathology. The patient was sent via air ambulance. With the films in his hand and the patient in front of him, the vascular surgeon gave us a call, he wasn't convinced. The CT of the descending aorta with the notch was not impressive to the vascular surgeon and to him, at this time it looked more like an artifact, typical of what he had seen in the past. Yet, the pain was still unrelenting. Our discussion convinced him that a vascular study was appropriate. The vascular study was done, low and behold, there was clear cut evidence of an intimal dissection of the descending aorta, a rare and deadly diagnosis, with even the best vascular surgeon having a 50% mortality. For those unaware of this devastating and life threatening injury, trauma associated intimal aortic dissections carry a greater than 50% mortality rate. By the time most are discovered, it is too late for surgical intervention and death can occur in minutes. The Aorta has three layers to it, the intimal layer is the inner most layer of which the blood has direct contact. With a cut or laceration into this layer, this layer can actually start to dissect open letting the blood enter into potential space between the intima and the middle layer. As this blood dissects

5 this layer down, eventually the dissection becomes large enough to actually rip apart and occlude the aorta, causing a massive amount of pressure from the beating heart with nearly instantaneous rupture of the aorta, spilling 50% of ones blood into the contents of the chest within minutes, resulting in a very painful yet quick death. Historical descriptions for autopsy diagnosis, reveal a sudden on set of severe and unrelenting chest pain, collapse within minutes and death with no chance of recovery. It has been mistaken to be a heart attack on many occasions, with resulting autopsy revealing the truth. The 20 y/o was taken for immediate thoracic surgery to undergo an aortic vascular repair. The surgeon got there in time and repaired the traumatic defect. Undetected, or should the patient not have gone to the ED for evaluation, he would have undoubtedly been dead in under 48 hours. The patient recovered very well from this surgery. He was back in school in 2 weeks with a much greater appreciation for life.