The Time Bomb

4/4/07 | 60Gunner

[60Gunner]

 

It started innocuously enough.

A male in his mid-forties came to the ER because he had turned while lifting a box and felt a sudden sharp pain in his back. When he arrived at Triage, he was walking, talking, alert and oriented, and his blood pressure was high-normal. The front was full, but the Fast Track area had an open bay and there was nobody else waiting.

He was walked back to our Fast Track area and given a gown and a couple of warm blankets. Standard procedure is to strip a patient with back pain down to the skivvies in order to facilitate an assessment and x-ray (if needed) of the entire spine. It's a procedure that has helped us discover some pretty serious back problems in the past.

Well, we discovered something serious this time, too. And it had nothing to do with his spine.

On entering the patient's exam bay, the first think I noticed was that the patient was looking at his legs. The second thing I noticed, having reflexively followed the patient's gaze, was the patient's legs.

The left leg was normal in color all the way down to the toenails. The right leg was pale blue and mottled, and his toenails were white.

Oh, crud, I thought.

You know that horror movie music that plays when the victim is chased into a hallway and sees a door, the monster is breathing down the victim's neck, and the hallway suddenly gets really, really, really long and the doorway gets farther away? You know, the music that accompanies the stretching hallway scene?

I call that music The Song of "Oh Crap" in D Minor.

And that ominous dirge was swelling in my ears as I rather begged the patient to lie on the stretcher- gently, please... for Pete's sake- GENTLY. I checked for pulses in both feet. The left foot had a good strong pulse. The right had none. I then laid my hand on the patient's abdomen and felt the peculiar, strong whooshing pulsation underneath my hand that I really hoped wouldn't be there but knew had to be. I could feel it all the way from the epigastric region to three finger-widths below the belly button.

Music swelling, hallway stretching, bad feeling getting worse...

I stepped away from the patient and his extremely bewildered wife and came as close to dragging a Medical Doctor into the room by the scruff of the neck as ever I could. In the seconds that transpired for the journey, I rattled off everything I knew at the speed of one of those disclaimer guys at the end of a car commercial.

I finished with "Take a look, Doc," as I knocked on the wall and swept the curtain aside.

The doctor introduced himself as he lifted up the blanket covering the patient's legs, and his eyes just about did that bah-WOOO-gah thing in the cartoons. He checked pedal pulses and asked if the patient was feeling alright. The patient said he felt fine other than the pain in his back and the numbness in his right leg. The MD and I excused ourselves and exited. My MD called the MD overseeing the trauma rooms up front, and I called the charge nurse and told her (as opposed to asking her) to clear a trauma room pronto, because my patient was coming in.

The charge nurse initially voiced her dismay at this rather abrupt breach in professional decorum. I cut her off (which I never would ordinarily do) and laid out the situation. She said she'd bump the asthmatic smoker into the hall for my patient, and to give her two minutes for the room to be ready.

Two minutes later, I was wheeling my patient into the trauma room. RNs and Techs swarmed the man, slapping monitor leads, a blood pressure cuff, and a pulse oximeter sensor on him. Capitalizing on the great big bulgy veins the patient had in his antecubital fossae, I shoved a 14-gage catheter into each arm. As we worked, the doctor explained the reason why we were moving so fast, and that a CT scan would tell the tale.

Fifteen minutes later the MD, Charge RN, ER Tech and I stood in the film room, staring wide-eyed and aghast at a monster. The source of the patient's back pain and leg numbness was a huge aortic dissection going almost the entire length of the patient's abdomen.

Ominous music getting louder, panic welling up in the throat...

The MD ordered meds to keep the patient's blood pressure down and immediately got on the phone with a local hospital that specialized in the procedure that this patient had to have if he was to survive the night. And that was a big, big if. While the MD made his connections, I did everything but pack the patient in egg crates- for all the good it would do if his aorta split open. If it happened, the patient would die within seconds and there would not have been a thing any of us could have done about it.

By this time, the patient and his wife were fully aware of what was happening. We told them the whole story, including the part about how he could simply start bleeding to death at any moment, and that he would barely have enough time to say goodbye before he was gone. Also by this time, the entire Emergency Department was electrified by the case. Everyone was hushed and tense. The other nurses gave me supportive pats on the back and looked after my other patients as I remained in the patient's room, watching for signs of sudden exsanguination as the patient and his wife quietly talked.

The wife had at one point called their children and told them to come to the hospital right now. Apparently, one of her kids balked and she snapped, "If you don't come now, you may not get to say goodbye!" All the kids were in the room amazingly fast. They were quiet, too, as if even a whisper would set off the bomb.

All this time, the patient was extraordinarily calm. Somber as hell, but calm. I am still amazed at his fortitude.

The Charge RN came in and told me that the Life Flight was enroute and to get the patient ready. The patient's wife collected her things and she and the kids left for the other hospital after saying their optimistic chorus of "See you later."

The chart was copied and everything was in order by the time we heard the first faint vibrations that increased rapidly to that distinct, chest-thumping, head-splitting thrum of the Agusta helicopter flown by the airlift team.

I waited with the patient in the ER entrance, shielding him from the rotor wash as best I could. The Agusta settled on its landing gear and the ear-splitting racket died down to the more tolerable roar of the turbine as the rotors dumped their lift. The flight nurse (a 5'4" keg of pure dynamite and a dear friend of mine for many years) met us halfway out.

"Hey, Gunner!" she shouted.

I patted her helmet and said, "Dang, Bird Woman, I gotta get one of these!

I rattled off a fast report as we trundled the patient to the whirlybird with our backs hunched. She introduced herself to the patient with a bellow as I helped her get him into the aircraft. I shook the patient's hand and said, "She's the best nurse in the whole universe. You got the first team tonight, buddy."

"I know. Thanks for everything."

Smiling ear to ear under her big ol' helmet, Nurse Dynamite patted me on the cheek and shouted in my ear, I got him, sweetheart!

I scooted out of the helicopter and shouted "Away, flying nurse creature!" with a shooing motion. I scurried back out of the rotor wash as the Agusta's characteristic thunder again filled my brain with fuzz. As the aircraft broke ground, Nurse Dynamite waved. I waved back and walked back into the ER to call report to the receiving RN at the other hospital as the sound of the rotors rapidly dissolved in the cold night.

[60Gunner]

You can find an excellent explanation of aortic dissection, as well as causes, treatment and prognoses, here. He may not have literally had an explosive device implanted in him, but his own body had manufactured something that would have killed him just as quickly. And when the aorta ruptures, it is over in seconds. We had a patient a week previously who was not as fortunate as my patient. But the MD who tended to the patient who died also tended to my patient. And this MD is fantastic.

[Logophile]

You need to make a book of these stories.

That is what I was going to say.

Keep writing, and find a publisher.

[60Gunner]

Almost a sure death sentence.

If the aorta lets go, it is 100% fatal. Nobody survives it.

[null and void]

and what exactly is it?

Imagine you have one of those pressure hoses with the braid between the inner and outer tube. The braid is what keeps the inside tube from swelling up like a balloon and bursting, the outer tube is just there to protect the braid from getting frayed.

Now imagine that the inside tube has a hole. The water quickly pours into the gap that has the braid, the inside tube starts to collapse and the outer tube begins to swell up.

Very soon you are going to have a wet floor...

[Gator113]

Great read.

Being one that has been in the hospital 6 times in the past 4 years, I really appreciate the A-Team.

Great job....you gave that guy a fighting chance.

[Lazamataz]

Unlike everyone else, I DON’T want to know how it turned out.

[streetpreacher]

And you don’t know if he made it?? This story stinks!!

[streetpreacher]

You’re probably right.

[TASMANIANRED]

My worst one died but took a while to do it.

She were on a monitored unit when it blew.

She got to OR pretty promptly and they managed to fix it.

She had about 27 liters of fluids and blood and I was trying to keep her alive in ICU from about hour 8-12.

DIC was so bad she was bleeding from her eyeballs. I couldn’t pump in blood fast as fast as she was loosing it.

We fought the good fight but the Grim Reaper won .

[60Gunner]

Oh, I know the ending. You will be amazed. But the process of describing it will take another entire post. I am working on it. Please stay tuned.

[MHGinTN]

I love these narratives. Used to turn to them first thing when my Discover Mag arrived.

[exit82]

Laz—check post 30. Maybe your tagline is prophetic.

We already know that it is true.

[Judith Anne]

My grandfather had a big aortic aneurysm. He went to his dr, unbuttoned his shirt, and said, “My heart dropped” and sure enough, it looked just like his heart had dropped into his abdomen—a big pulsing lump.

He lived for over a decade, after the surgical repair.

*sigh*

[Dr.Zoidberg]

Well get to it man, we’re all hanging here with baited breath.

And right now the bait it trying to wriggle off the hook!

[KoRn]

I’m interested in hearing the end of this. Please add me to your ER list. My wife is a nurse. I often show your stories to her and she reads them when I find them.

[REDWOOD99]

Please add me to this ping list. And tell us what happened to the guy!

[streetpreacher]

Thanks. I’ll be keeping an eye out for it. You do write really well.

[Dr.Zoidberg]

Oh and while you’re at it, please add me to your ping list as well.

Thank you.

[swmobuffalo]

Please add me to the ping list! Your stories are great!

[verum ago]

now, I have no medical training, but for what it's worth both my older brothers (one is a paramedic, the other in med school) like to show me pictures of medical problems, especially sample xrays and CAT scans. One, I do not recall which, has shown me pictures of various aortic dissections. Now, in the picture above, I think the line that the red arrow points at is the intima, meaning that the entire lower left third of the aorta in the pic is false lumen. Is my interpretation correct? Because if so, whoa! That's waaaaayyy larger than any dissection my brothers have showed me a pic of (like, Good G-d!). when I first saw it and decided that's what it was I said Wloud 'I'm looking at death'. Please tell me I'm an amateur idiot (which would be redundant) and that I'm wrong. Because I hope for the sake of the patient I'm really way off. That's just frightening.