I’m currently working at a community hospital (more on that later). The nurses, paramedics, and EMTs are all friends with each other, so the if the EMS crews are bringing in something even slightly concerning, they try to give us a heads up so we can be ready, and we appreciate it when they do. So when they called at 3am, stating that they were bringing a 91 year old guy in with back pain, you had to wonder what it was they are worried about. Well, the ONE thing you would worry about in an old guy, with sudden onset back pain at 3am, bad enough to call an ambulance, is an aortic dissection or anneuryism.
The attending I was working with, just graduated our program, and it was just the two of us on at that hour. We were having a good time in between patient, catching up on a few laughs and stories. But when the medics called in he was like “soon as this guy rolls in, put the ultrasound on his belly”. About 10 minutes later the guy rolls in, wide wake, totally with it, in appearing in a perfect state of health, except that he’s complaining about his back killing him. “I got up to use the bathroom, and when I sat back down, my back just started killing me, worst pain I’ve ever felt, non stop for 30 minutes”. So we sat him in the bed, got him to lay back, and I put the probe on this belly. Before even looking at the screen, you could make an easy prediction of what you were going to see. I could feel the probe throbbing in my hands, boom, boom, boom, at oh, about 72 BPM. And when I turned to the screen, I saw….
That line is measuring the diameter of the aorta. A normal person’s is about 1.5cm at the spot I was measuring. So bam, this guy is now officially having a AAA (abdominal aortic aneurysm). They are fairly safe with a low risk of rupture under 5.0 cm, but above that, they are the proverbial ticking time bomb, especially when they start hurting. But okay, this guy is just fine right this second, still perfectly stable, but lets call surgery sooner rather than later. I step out, show my attending the image… and see him turn a slighter shade of paler (he’s pretty white to start with), which is understanding given it’s only his third time being a single coverage attending. So we get surgery on the horn, and the nurse pops guys “GUYS! HE’S LOST PULSES”….. SHIT. Did this guy just rupture his AAA in our ED? Yeah… he did. But, because our nurses are so bangin awesome, they started putting that second line in the moment I showed them the ultrasound, so, for the time being we were one step ahead, as we had the classic “two large bore IV’s” already in place. Fluids wide open, CPR under way, epi in, blood on the way, intubated with good breath sounds, surgery at the bedside,”IF you get pulses back, the OR is getting ready”. And we did,we got him back after only two rounds of EPI, got 3 units of blood into him, 3 L of fluid, and he kept holding steady, good blood pressures and heart rates, and he got wheeled up to the OR. When I left 3 hours later, he was still there, but more importantly he was still alive. If this had happened 15 minutes earlier, he probably wouldn’t have been.
The weirdest part for me, was that during this whole code part…. it was deathly silent in the room. I’ve never heard a code so quiet. Everyone was just doing their job, and doing it quietly perhaps. The machines and monitors were’t beeping, you could have heard a pin drop it was so quiet. I don’t know if that’s significant for anything, but it just struck me as bizarre at the moment, like, are we forgetting something here? Is there some crucial piece of equipment that’s missing that normally makes all this unnecessary and useless background noise or something? It was just weird.