Tuesday, September 16, 2014

Aortic dissection leads to man's death in the ED: His wife's perspective

A woman wrote to me about the day her husband died. I have edited her email for length and clarity and changed some insignificant details to protect her anonymity as she requested.

Joe passed away outside in the parking lot while they were getting on a helicopter for transport to a hospital equipped to do his surgery.

He had presented to the ED in terrible pain with lots of thrashing and writhing. 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. This was in addition to being very pale and diaphoretic upon admission. This is when I felt a dissecting aorta should have been suspected.

I don’t recall the vitals in the beginning, but they were changing and his blood pressure was dropping very fast. As soon as they finished the EKG-in the first 5 minutes of the visit, I asked the doctor about John Ritter's death [the actor died of a dissecting thoracic aneurysm in 2003]. First I asked if he could check for the condition that caused John Ritter's death. I called it an abdominal aortic aneurysm. The doc corrected me and said that it wasn’t an AAA it was a dissected aorta. I said OK, then check for that. This was 1 hour before the CT scan that led to his diagnosis.

After the conversation about the dissected aorta the doctor said they are going to check for a lot of things. I am getting pretty anxious at this point because Joe was in so much pain. I have never seen anything like it. The nurse walked in really slowly with a syringe and a paper cup. She went to the keyboard and starting asking him questions. Again...really slowly. I kept looking at that syringe wanting her to give him that shot. It turns out the shot was for nausea.

Then she gave him the cup with Maalox and lidocaine and said that would let us know if it was heartburn or not. She said we had to wait about 5 minutes. Joe assured her that it was not heartburn. After about 15 minutes, I went to the nurses' station to ask for help. I said that I hated to be one of those kind of people that go to the nurses' station to ask for help, but we really needed it. I said please do something for his pain. The response was “The doctor is putting in an order now”. Then she told me that first they are going to take him for a chest x-ray. After x-ray he got his first dose of morphine. That was the end of the casual part of the visit.

When the CXR came back there was a noticeable “flare” of the ascending aorta. Then we had to wait for the radiologist to call back and confirm. That ate up about another 20 minutes. Confirmation was made and CT scan was ordered and another dose of morphine was given because Joe couldn’t be still for the CT. Things went into full tilt at this point. Life flight was called; surgeons were contacted. We had to go to another hospital because they couldn’t crack a chest at the hospital where we were. I did not realize hospitals had these kind of limitations. Had I known, I would have taken him straight to our medical center.

He went into cardiac arrest as they put him in the helicopter. The doctor came out and started doing chest compressions. Common sense told me that chest compressions were not going to restart a heart with a tear in the aorta. I knew it was over at that point. The doc came to me and said they were going to take him back in and put a tube in to get him breathing. I knew he had bled to death and the tube was not going to do anything.

When he was recapping after Joe died, the doctor said to me that he had wanted to make sure this was not a lot of drama. I could tell that was his attitude from the get-go. Joe had every symptom of an aortic dissection. He may have had about a 30% chance of surviving the surgery, but they let the clock run out.

My husband was 54. We had two children late in life—my husband's only children.

I do blame misuse of the ED. As doctors, you have to sort out the motivations of every patient, not just the symptoms. Not to mention the people that use the ED as a regular doctor's office. I get irritated when patients complain that the ED doc wasn’t nice and compassionate when they went to the ER for pink eye. They don’t know if this doctor just had to tell a man's wife that her husband died of an aortic dissection. That can affect a doctor's mood.

I feel like I am doing something good for my husband by creating awareness for ED misuse and overuse. I think the doc was skeptical about Joe’s pain. ED docs see all kind of crazy stuff. They see the good, the bad, and the ugly. I believe a kind of “burn out” contributed to Joe’s death. There were 2 pink eye patients the night we were at the hospital. How can an ED doc not be burned out?


884y said...

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.

JEN said...

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.

Skeptical Scalpel said...

884y, I agree. Lots of patients with drama and minor problems, few with dissecting aortas.

JEN, you need to speak up. But as this case shows, even that doesn't always work.

Anonymous said...

"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.
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?

artiger said...

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.

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.

Skeptical Scalpel said...

Anon, I share your concerns.

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.

Anonymous said...

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. Sherry

Anonymous said...

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

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.

Skeptical Scalpel said...

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.

Anonymous said...

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.

hope said...

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.

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.

Skeptical Scalpel said...

Anonymous (Joe's wife), thanks for adding some more details to the story and for letting me post all of it.

Hope, your comments are appreciated. Thanks for being such a loyal reader.

Anonymous said...

Anonymous (Joe's wife): I am very sorry for your loss. Thank you for sharing your story.

Natalie said...

"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."

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.

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.

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.

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?

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.

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.

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.

Skeptical Scalpel said...

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.

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.

Anonymous said...

Let's just admit what actually happened here: Someone made a mistake.

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.

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.

See also:

Skeptical Scalpel said...

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.

Kenya said...

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.

Skeptical Scalpel said...

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.

Kenya said...

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.

Heather said...

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.

Skeptical Scalpel said...

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.

I hope everyone stays well.

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