tag:blogger.com,1999:blog-4968787219619380438.post4331175116699944157..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: Aortic dissection leads to man's death in the ED: His wife's perspectiveSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger22125tag:blogger.com,1999:blog-4968787219619380438.post-61461093425031585392016-05-27T10:52:49.374-04:002016-05-27T10:52:49.374-04:00Heather, thank you for sharing your story and for ...Heather, thank you for sharing your story and for the excellent advice about having family members get checked to see if they have the problem.<br /><br />I hope everyone stays well.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-90848728692223930192016-05-27T05:13:31.462-04:002016-05-27T05:13:31.462-04:00Also get your family checked. My 40 year old siste...Also get your family checked. My 40 year old sister was in an accident and a CT scan found an ascending aortic aneurysm. All first degree relatives got checked. Of five sisters, three of us have aneurysms (neither brother has one - yet), and now we suspect the other sister who died at 52 also had one (appeared to be a cardiac event, instant death). Early onset is a cue for a genetic trait. (tested,we don't have any of the associated already identified genes, unfortunately.) Everyone is under care, now, and the negative ones will be rechecked periodically over their lifetimes. Definitely improves the odds of survival, and having a medical alert bracelet that says aortic aneurysm will get you fast tracked in the ER/ED like nobody's business. Straight to the front of the line. (One sister had a gall bladder attack after the AAA diagnosis... No waiting, even in a busy ER. Fortunately just gall bladder.) I highly recommend the medical ID. Heathernoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-34994927294248951692016-04-26T14:53:01.781-04:002016-04-26T14:53:01.781-04:00I know and I think that is why they sent me home t...I know and I think that is why they sent me home the first night. I am suppose to have a PAD test done at my next follow up. I asked the cardiovascular surgeon how this could have happened to me and he gave me an honest answer...he doesn't know. I've had a follow up cat scan and there is an area that he wants to keep an eye on. My parents nor grandparents had this happen to them. Thank you for the feedback and I'll be sure to ask about atherosclerosis. Kenyahttps://www.blogger.com/profile/03542152369458217259noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-34842340994410585412016-04-25T16:43:38.826-04:002016-04-25T16:43:38.826-04:00Thanks for commenting. I hope you are feeling bett...Thanks for commenting. I hope you are feeling better. You are very young to have had a ruptured AAA especially as a woman. I hope you have been worked up for early atherosclerosis, hereditary diseases etc.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-38288540734091545162016-04-24T21:38:55.703-04:002016-04-24T21:38:55.703-04:00You're right. Nothing has changed. I went to t...You're right. Nothing has changed. I went to the emergency room because I was having back pain and they sent me home with pills for nausea and muscle spasms. The next day, I was rushed to the ER again and this time, my friend had to get aggressive and that's when they found the ruptured AAA so I was air lifted to another hospital for emergency surgery. I guess the aneurysm dissected the day before because there is no way I would have survived a bleed out overnight. The rupture just happened in November of 2015 and I'm still recovering both physically and mentally from this trauma. I was 41 at the time.Kenyahttps://www.blogger.com/profile/03542152369458217259noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-73058934443364764222014-09-24T08:31:18.668-04:002014-09-24T08:31:18.668-04:00I agree that a just culture would be nice. So far ...I agree that a just culture would be nice. So far it hasn't happened in medicine. I blogged about this 2 years ago (http://skepticalscalpel.blogspot.com/2012/05/are-you-afraid-to-be-wrong.html with a link to an earlier post in it). Nothing has changed since then. I doubt it will ever happen.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-18613139679584403942014-09-23T22:11:33.753-04:002014-09-23T22:11:33.753-04:00Let's just admit what actually happened here: ...Let's just admit what actually happened here: Someone made a mistake. <br /><br />I am NOT saying that the standard of medical care was violated. I am NOT saying that I could or would have done it better. <br /><br />As a junior surgery resident, let me emphasize how important it is that we don't hide this fact - that doctors make mistakes - and instead that we bring those mistakes into the light, that we adopt a "just culture" regarding physician errors, and most importantly, that we learn from them.<br /><br />See also:<br />http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that?language=enAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-12652037531022869892014-09-21T07:58:46.878-04:002014-09-21T07:58:46.878-04:00Natalie, thank you for your impassioned defense of...Natalie, thank you for your impassioned defense of the ED, but surely you must concede that a patient who looked like Joe should not have had to wait at all. Wouldn't you assume that a tracking board that can be seen from the waiting room would depict the actual situation in that ED? This was a small hospital. I don't think it had zones.<br /><br />BTW, the "we're understaffed" excuse doesn't cut it. The triage system that most EDs employ should have recognized that Joe was the sickest patient in the place that night.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-25110253950117440432014-09-20T15:36:57.173-04:002014-09-20T15:36:57.173-04:00"My biggest concern is how long we had to wai..."My biggest concern is how long we had to wait in the exam room alone...I took a look at the board in the hall and saw that there was one other patient...Her situation was not urgent. There was no over crowding in this ED that night. Even the Pink Eye that came in later went right back to an exam room."<br /><br />I work as a scribe in the ED, so I'm not a physician and don't have professional training in medicine. But I see this type of concern from patient's family members every shift. Unfortunately there are A LOT of factors involved in who gets a bed/who gets seen when etc. and it's not always clear to the family/patient as to WHY Ms. Smith gets seen before Mr. Brown. <br /><br />In the ED I work at, there are 5 different "zones" according to acuity. So when families or patients see other patients being called back before them, they get upset. But it might just be because they're going to a different zone, with a different amount of open beds. <br /><br />Just because you looked at one tracking board doesn't mean it's accurate. There are lots of whiteboards in the ED, so maybe you didn't see the full patient load. In the ED I work at, the whiteboards aren't even updated because almost everything related to bed tracking/patient census is managed on the computer. <br /><br />How do you know that the other patient's situation wasn't urgent? Are you her doctor? Did you examine her to determine her acuity?<br /><br />Even if it LOOKS like there is "no overcrowding" in the waiting room, there might be a backup in the number of available ED beds open because patients are waiting to be admitted to beds upstairs when there are no openings upstairs. There are sometimes lulls in the number of patients checking into the ED, but that doesn't mean the staff isn't still very busy dealing with things. <br /><br />Even if it LOOKS like there are open ED beds, there is often (where I work) not enough nursing staff to cover all of the beds. Where I work, this happens because when nurses call in sick they don't have someone come in to cover them, and they can close a whole zone because of nurses calling in sick. But when the ED physicians call in sick (very rare), they MUST get coverage because that's just what needs to happen.<br /><br />Also, there is a WHOLE LOT of documentation the physicians/scribes and nursing staff must do, so even if they disappear from your sight doesn't mean they're not frantically working on filling orders and trying to arrange for your care. Trust that they're working as fast as they can and aren't purposefully ignoring you. Natalienoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-69005015860153198462014-09-18T21:02:01.573-04:002014-09-18T21:02:01.573-04:00Anonymous (Joe's wife): I am very sorry for y...Anonymous (Joe's wife): I am very sorry for your loss. Thank you for sharing your story.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-19987817974244744372014-09-18T19:00:10.727-04:002014-09-18T19:00:10.727-04:00Anonymous (Joe's wife), thanks for adding some...Anonymous (Joe's wife), thanks for adding some more details to the story and for letting me post all of it.<br /><br />Hope, your comments are appreciated. Thanks for being such a loyal reader.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-34409636069908871972014-09-18T17:21:18.749-04:002014-09-18T17:21:18.749-04:00That's a very sad story. Type A ascending aort...That's a very sad story. Type A ascending aortic dissections can be so quick and fatal if they're not recognized quickly. I work at a tertiary care academic medical center in vascular surgery. I've also had to rotate at smaller hospitals in rural areas. It's true that patients can wait around for a long time for answers and, even when there is one, transferring a patient from an outside hospital to a larger academic center is even harder. It sounds like this patient was triaged incorrectly from the beginning. I know I am biased because I see dissections more regularly than the average person, but anyone with diaphoresis and focal neurological symptoms should be put into an exam room and seen right away -- unless they are well-known "frequent fliers" in the ED. Acute coronary syndrome and stroke should be at the top of the list, but aortic dissection should be a strong third. I wish the story had ended differently. It takes quick triage, transport and a cardiac surgeon all within expeditious time to save someone like this. Even then, if there is a descending thoracic component, patients who get the surgery may still have terrible complications from false lumen thrombosis. It's hard to say whether there could have been a better outcome, although one wishes for better systems processing. <br /><br />I've been so busy lately Skeptical, hardly any time for blog reading or commenting, but I'm glad I saw this one. Thanks for posting. hopenoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-17467473710438961572014-09-18T12:37:39.314-04:002014-09-18T12:37:39.314-04:00To answer one of the questions, No Joe had never s...To answer one of the questions, No Joe had never seen a Dr for Pain and never really had much of a history medically. Just routine stuff from time to time. He also had normal BP and his Lipid Panels all came back looking good before this incident. I also want to mentioned that Joe made a comment about how good he felt that day (he suffers from allergies) he said he hadn't felt this good in a long time. About 3 hours later "it" hit out of nowhere. My biggest concern is how long we had to wait in the exam room alone. I don't think we should have been alone at all. I took a look at the board in the hall and saw that there was one other patient. Her situation was not urgent. There was no over crowding in this ED that night. Even the Pink Eye that came in later went right back to an exam room. I hated seeing Joe in that much pain. When we got in the exam room I did ask the Doc if they could give Joe something for pain. I got a funny look and no answer. I wondered if the Doc thought I meant that we wanted a prescription for Vicodin or something. I meant give Joe something in the IV that they were putting in. That is when I started to feel like the Doc did not know quite what to think of us. That is what leads me to be concerned about "burnout" for ED Docs.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-24849487109160520652014-09-18T08:30:33.284-04:002014-09-18T08:30:33.284-04:00That the ages were the same was quite a coincidenc...That the ages were the same was quite a coincidence. After Ritter's death, his brother was worked up and found to have the same problem which was electively repaired.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-71733193869313616922014-09-18T00:26:34.260-04:002014-09-18T00:26:34.260-04:00Yeah, the idiots who clog the ED are a problem, bu...Yeah, the idiots who clog the ED are a problem, but this doc utterly failed the patient and his survivors by not catching a "can't miss" diagnosis--even after it was handed to him by the wife! It's too bad the doc's trivia knowledge didn't extend to realizing that John Ritter died at ... age 54. Benefit of the doubt = revoked<br /><br />Involvement of the innominate artery explains everything, even the BP if they neglected to check left arm and leg BPs. The odds are never great in TAA but the treatment as described made the outcome a near certainty. It may be too much to expect the public to appreciate the subtleties of which hospitals provide thoracic aortic surgery. However, lacking other info, the best call was to go to a nearby ED to maximize the chances of halting further progression with medical therapy (B-blockers, etc) But only if the dept is capable of making a timely Dx.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-34795561782443898392014-09-17T22:33:38.245-04:002014-09-17T22:33:38.245-04:00I don't think it's unusual care at all. To...I don't think it's unusual care at all. Too many assumptions are made in the ER. I have a friend who broke her leg today in a car accident. The trials she is being subjected to are shocking but not surprising, if that makes sense. SherryAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-11878750889480496082014-09-17T08:44:00.373-04:002014-09-17T08:44:00.373-04:00Anon, I share your concerns.
Artiger, I agree he...Anon, I share your concerns. <br /><br />Artiger, I agree he had a very low to no chance of surviving. The case is a good lesson for all of us about listening to patients and looking for the worst possible diagnosis instead of assuming its all drama.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-69331780989358613542014-09-17T08:31:37.738-04:002014-09-17T08:31:37.738-04:00Wow, her narrative didn't end the way I though...Wow, her narrative didn't end the way I thought it would. Most people would have taken the opportunity to open up with both barrels. She is certainly taking the high road here.<br /><br />I work in a hospital such as the one she described, probably smaller. If someone shows up with that problem, they are likely not going to survive, even if the diagnosis is picked up more quickly. That is something of an accepted sacrifice for living in a rural area, but it is probably a good idea to be familiar with the capabilities of your local hospital prior to needing it. artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-29557515407200670962014-09-16T23:40:45.368-04:002014-09-16T23:40:45.368-04:00"His right hand was very cold. His right arm ..."His right hand was very cold. His right arm tingled to the point of hurting bad. The vision in his right eye was cloudy, and his hearing was muffled on the right." I have never seen a faking patient make up a story this complicated.<br /> There is a genius maneuver known as pull the wife aside and ask, Has he ever gone to the doctor before for pain? Is this usual for him?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-43683715353904587302014-09-16T21:44:03.065-04:002014-09-16T21:44:03.065-04:00884y, I agree. Lots of patients with drama and min...884y, I agree. Lots of patients with drama and minor problems, few with dissecting aortas.<br /><br />JEN, you need to speak up. But as this case shows, even that doesn't always work.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-86992398597600046132014-09-16T19:01:22.782-04:002014-09-16T19:01:22.782-04:00This is crazy sad. Unfortunately, every time I...This is crazy sad. Unfortunately, every time I've been in the ER (recently my two year old got taken by ambulance), I've had to be very aggressive in getting them to tell me anything, or do anything.JENhttps://www.blogger.com/profile/18357044911025475893noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-61903104822247127222014-09-16T18:17:15.032-04:002014-09-16T18:17:15.032-04:00Sad story. I don't think 20 to 30 mins in dela...Sad story. I don't think 20 to 30 mins in delay to diagnosis cost this man his life though. And it is very true that the large number of patients who complain of 'the worst pain of my life' who are being dramatic or drug seeking is high, and that this can cause a degree of skepticism when patients present in severe dramatic pain.884yhttps://www.blogger.com/profile/03642794630187791906noreply@blogger.com