Its great when colleagues pat you on the back and give you the whole “great catch” accolade of a rare diagnosis caught early or a potentially life threatening condition that may have been missed being picked up. Its even nicer if the compliments come from the doctors in the Accident & Emergency department.
But, like most things do, this got me to thinking and reminds me of a job I attended a few months back.
I was called to a 50ish year old female (Margaret) who was complaining of left loin pain. She had developed this pain earlier in the day (about 4 hours before calling) whilst moving some furniture in her front room. The pain was starting to become very troublesome for her and despite taking some of her normal analgesia, she eventually decided that she needed to call for help.
I arrived in my Rapid Response car at 04:30 to find her slouched against the fridge in the kitchen. She was conscious alert and orientated, but was pallid and had beads of sweat coming from her forehead.
Her radial pulse was strong and regular at about 80 beats per minute, and whilst she was telling me what was going on, I quickly took a manual blood pressure reading which was 130/75. Her skin was cool and moist and her pain persisted. I knew already that I would be requiring a crew so radioed in my request for a Category B crew to back me up.
She told me that she had come through to the kitchen to get some water when all of a sudden the pain kicked in and the next thing she knew she was waking up on the floor and I was coming into the house.
With her observations within normal limits and her pain where it was I started considering the various causes of loin/kidney pain but I also wanted to do my full abdominal exam. I didn’t want her moving around too much at the moment, and since I was all on my lonesome, I asked Margaret if she would just lie back onto the floor for a moment so that I could feel her abdomen. As is my usual routine, I start on the least painful area and work towards the area of chief complaint, so I started gently palpating the right side of her abdomen which was soft and not particularly tender. As I moved through the various sections of the abdomen, I started to feel a hard structure.
At first, I thought she was tensing her abdominal wall and guarding against my pressure, so I asked her to relax her abdominal muscles which she said she was doing. This time I palpate just a little deeper and felt the curving edge of a large pulsatile mass in the centre of her abdomen. As my finger tips found the edge of it, I moved my thumb across to feel for the other side. I had to stretch my hand as wide as I could to find the other edge.
Margaret had the largest abdominal Aneurysm I have ever felt in 20 years in the health service (including 5 years in the operating room).
I looked over her again, and added this finding to the rest of my assessment. I asked if she was aware of any problems with the “blood vessel ruining through her belly”, to which she replied that she did not. She had no significant medical problems other than a touch of arthritis.
So……My findings now were a 50 year old female with a 4 hour history of left loin pain, a collapse with a loss of consciousness, normal vital signs at the time of assessment and a frankly huge palpable aneurysm.
I decided to go with my gut feeling of a retroperitoneal leaking AAA (abdominal aortic aneurysm) and upgraded the crew to a Category A response. I explained what my concerns were to Margaret and that I may well be over reacting but in my opinion it was better to be safe than sorry. Two 16 gauge cannulas and two 500ml bags of saline later (hung but not running) and the crew arrived on scene.
As they entered the house, I could see the all too familiar look that said ‘ this is a Cat A??? She looks fine!!’, and to be honest, by the time the crew arrived she was actually a good colour and feeling better in herself, but still in pain. I handed over to the crew and told them my provisional diagnosis. Again they look fairly unconvinced until I told the paramedic to have a feel of her abdomen. We made eye contact and i knew that whilst his hands were on her abdomen, he too would understand my rationale.
A couple of minutes later and she was on her way to the hospital with a pre-alert going in for a suspected leaking AAA.
Later on that night, I had the chance to go up to the A&E department and asked how she had gotten on. The Doctors in the office asked if I was the rapid that was on scene, and then proceeded to congratulate me on my quick diagnosis and said that the crew had mentioned that it was me that had ‘caught it’
Now, here is my point… Was it a good catch or was it just a medic doing a full assessment that found a hugely obvious aneurysm and assumed that it had something to do with a patients abdominal pain (although admittedly her pain wasn’t the typically taught location for a AAA)?
I always put my hands onto an abdomen when the patient complains of abdominal pain. If I don’t, I miss a vital part of the assessment process. Any medic who put their hands on Margarets abdomen would have found the AAA too.
Its nice to get the compliments, and it is nice to know that you have made a correct diagnosis, but in this case, it would have been nice to have been wrong – for Margaret.
I was informed that she had gone to theatre for her surgery but was fairly unstable after dropping her blood pressure in the resus room.
I hope she makes it off the table, I really do.