Case 9: Choose Your Own Adventure

[Triage Note: Abdominal pain, sudden onset at 1:30pm, crampy, right > left, lower quadrant. no vomiting or diarrhea. No chest pain]

It’s a Sunday in mid-October and it’s still beautiful outside – warm, sunny with a lazy breeze. Colourful. I have to work the weekend, but I can’t complain: I had the previous weekend off and spent it cycling with my family in Niagara.

The first patient I see has been waiting just over an hour – an eighty-eight year old with weakness. Urinary Tract Infection. The next patient is sixty-nine, and has an arrythmia. We sedate him, and shock him with two hundred joules of energy, resetting his heart to normal sinus rhythm. In the next hour, I will see an overweight woman with abdominal pain (gallstones), a seven-month old in respiratory distress (bronchiolitis), a fifty-one year old with cough (pneumonia), and a forty-five year old, too cool for helmets, who fell off an ATV (stupidity).

At four pm, I meet Bridgette Bender, a seventy-seven year old woman who volunteers four days a week. She arrived by ambulance just twenty minutes earlier, but was quickly offloaded onto a wheelchair, and she walks easily into an assessment room when my assistant calls her name. Her symptoms have resolved, and she feels silly for being in the E.R. She sits comfortably on the examination table and tells me what had happened: Two hours earlier, just after lunch, she was helping  with gardening at the Senior’s Centre, when she had a sudden sharp pain in her abdomen. There was no vomiting, and no diarrhea. She makes it clear that this happened just fifteen minutes after eating a cheese sandwich, and that it was likely related. She sat for a few minutes, and her friends gave her a glass of water. After half-an-hour, when the pain hadn’t completely resolved, her friends called an ambulance. “I’m sorry to waste your time,” she says, “I can see you running off your feet.” I tell her that it’s not a waste, and ask how she feels now. Her symptoms are gone, she says, and she asks if she can go home. I ask her more questions. She denies any previous medical history, denies having any cardiac or lung disease, and swears she’s never had any abdominal surgery. She takes no medication, does not smoke, or drink, and has no allergies. This is remarkable, I tell her, for someone her age. “I’m lucky,” she says, smiling. “I still drive, you know, and I take cancer patients to their appointments on Mondays.”

I examine her. Her skin is pink, flushed, and healthy. She is wearing makeup and her hair looks as if she was at a salon that morning. Her heart sounds are normal and her lungs are clear. She reclines onto the table and I palpate her belly: no tenderness, normal bowel sounds. A nurse has already drawn blood under a directive – and has checked off the cardiac panel. I ask whether or not she’s had any chest pain or shortness of breath. She denies this and points to her lower abdomen. “It was down here – very crampy, and sharp.” I scratch out the cardiac panel and check of ‘abdominal.’ She asks again if she can go home. I tell her that blood has already been drawn, and that we should wait for it. I also tell her that she should have an x-ray. “It sounds like you may have had a partial obstruction – a blockage -and sometimes we can see evidence of this on an x-ray.” She thinks this is unnecessary but agrees. I consider, for an instant, sending her home. In fact, had the blood work not already been drawn, I may have let her leave after the initial exam.

Thirteen minutes after my assessment, her nurse comes in and takes her history again. Her note will echo what Brigette has already told me: ‘Sudden onset of abdo pain – felt like gas and is relieved at this time. No urinary complaints. Had normal bowel movement today. Patient sent to X-ray. No apparent distress.’

Ninety minutes later, I’m ready to re-assess Bridgette. Her blood work and x-ray are back. Her white count is mildly elevated at 14 (normal is ten). Her hemoglobin is normal, her electrolytes are normal, as are her liver and kidney function. The x-ray is picture perfect. She is sitting impatiently, waiting for me. I’m ready to give her the good news – that it was likely the sandwich, or that she’s picked up a stomach bug. When I direct her to follow me, she practically jumps from her chair, and climbs onto the table. She nods ‘yes’ when I ask if she’s ready to go home. I ask her to lie down and I palpate her abdomen. It is totally soft, and she denies pain when I push, although she does grimace as she sits up. I ask her again. “Are you sure you feel well enough to go home?”

“Yes,” she says. “I think so.”

When I was young, I remember having a few ‘Choose your own Adventure’ books. A story would begin, and then the protagonist would hit a fork in the road, and the reader could decide how the book would continue. If you wanted to turn left, and follow a path into the forest, you could turn the page. If you wanted to turn right, and continue down the street, then you’d have to skip ahead to page ninety-six. Brigette, and her abdominal pain, reminds me of one of those books. There are so many forks in her story. When I reviewed the paramedics’ note, it was clear, that when they arrived on scene, her pain had resolved, and she was fine. She could have waved them off, and I would have never seen her. When I’d first assessed her, if she’d asked if she could go home, and had the blood work not been drawn, I likely would have let her – considering she was pain free, and insistent that the sandwich had upset her stomach. I stopped reading those books, because there was little logic or reason to them. The fork in the road was just a roll of the dice – and too many times, I’d lead my protagonist off the edge of a cliff.

And now, four hours after the onset of her abdominal pain, Brigette has minor discomfort, grossly normal blood work, and a pristine abdominal x-ray. And she wants to leave. All I need to do now is ask the nurse to take out the IV line that the paramedics placed in her left hand.

I reach out, and take her hand to help her down. And just as she steps down, she stops. She squints as if she’s thinking – trying to pinpoint what she’s feeling. “I feel dizzy,” she says, “all of a sudden.”

I lead her back to a chair and ask her to relax for a while. She already has the IV line, so I ask the nurse to give her some fluid. When she sits, she insists that the pain in her belly hasn’t worsened. “I’m just dizzy.” The IV line is hooked up, and I move on.

I see a forty-three year old suicidal woman who’s tried to overdose on a bottle of pills and a forty-ouncer of vodka. I see a cut finger that needs stitches. I see another urinary tract infection, a cold, and then I’m called overhead to see a fourteen year old with a peanut allergy.

Between patients, I ask if she’s alright. She smiles and nods, although she looks tired. And then, at seven p.m, Bridgette yells out to her nurse: “I don’t feel well! I feel dizzy.” Her nurse rushes to her, just as she slumps over in her chair. She’s pale, clammy, and it takes almost a minute to rouse her. And when she opens her eyes, she clutches her abdomen and moans. A stretcher arrives and she’s wheeled into the Acute Zone. Her blood pressure, which has been normal throughout, has tanked. Fluids are run wide-open through the IV. I put a bedside ultrasound onto her abdomen and within seconds, I see it: an aneurysm – a dilatation of her abdominal aorta. A weak spot that’s likely bleeding. Profusely.

I check to see who’s on-call for Vascular Surgery. There’s no one. I call locating and find that both of our Vascular Surgeons are out of the country. I call Criticall; She needs to be transferred as quickly as possible. Fluids and drugs are run through a second IV line to raise her blood pressure. I call the radiologist who agrees to do a CT scan to visualize the bleeding. Brigitte is grey now, her pressure too low to perfuse her vital organs. She vomits several times. Medication drips are increased as she’s wheeled off to the scanner. While she’s there, I speak to a Vascular Surgeon downtown. By the time she’s back, units of blood are ready for transfusion, and transfer arrangements have been made.

The scan shows a ruptured abdominal aortic aneurysm with active bleeding. By the time she’s scanned, the collection of blood that has already hemorrhaged into her abdomen is the size of a cantaloupe. The aneurysm – the area of weakness in her aorta, had likely been there for years, but had began leaking while she was gardening at the Senior’s Centre. And then, likely, it had stopped, or slowed significantly, for several hours. Her initial blood test, taken two hours after her first episode of pain, showed a normal hemoglobin. But the blood test taken twenty minutes after she passed out showed a hemoglobin thirty points lower than normal. Just before she passed out, the aneurysm had opened like a flood-gate.

Over the next hour, she’s stabilized, and less than two hours after she passed out, she’s under the knife at another hospital.

At each of our monthly E.R. meetings, we sit around a table, in the back room of a restaurant, and discuss cases like this. Usually, however, it’s the cases in which we’ve missed the ruptured aneurysm in the patient with vague, resolving abdominal pain. Or, we’ve missed the incapacitating stroke in the patient with tingling in her fingers, and no abnormalities on physical exam. Or, we’ve missed the massive, fatal heart attack in the patient who’s had chest discomfort and a normal cardiac workup.

Families come forward, angry, asking us how could we – how could we send home patients who were on the cusp of death, letting them die later that night, when they’d come to our Emergency Room for help. Two months ago, we reviewed the case of a ruptured thoracic aorta – a patient who’d come in with chest pain, that had resolved. His cardiac workup had been completely normal. A Coroner, seated at the table, asked why we didn’t scan every patient with chest pain. The question was absurd. If we did, we’d unnecessarily radiate thousands of people, bankrupt the health-care system, and bring the entire hospital to a standstill. “Well, then,” another Coroner now famously said, “why don’t you just scan the ones who have a thoracic dissection.”

Twenty-four days later, Brigette was transferred back to our hospital for recuperation. She’d just barely made it off the table, she’d run into renal failure, and she’d had a tracheostomy because she’d been maintained on a ventilator for so long. But she was alive, and she was recovering.

And the only reason she was alive, was that her aneurysm had chosen to bleed profusely just as I was re-assessing her. I didn’t catch the aneurysm; the aneurysm caught me. It could just as easily have started to bleed again later that evening, as she was sitting comfortably at home, watching TV. And if it had, she would have been just another case to discuss at our monthly meeting.

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