I saw a patient today who has become a semi-frequent flyer. She has been in for chest pain, had MI’s ruled out, received, narcotics, reassurance, the run around, etc on several occasions. When I first saw her come in I was planning to do more of the same. After-all, we have tons of patients who complain of pain all over and no matter how big of a work-up they get, it usually turns out to be a fruitless waste of time and money. None-the-less, whenever a patient mentions back pain, chest pain, and abdominal pain during the same visit I still wonder if it is being caused by an aortic dissection (or aneurysm). I typically ask a few key questions, and the answers don’t often raise more red flags, which I feel lets me off the hook.
Sometimes I ask these questions grudgingly because I’m not sure I really want to know the answer, especially if I am nearing the end of my shift and trying to wrap up, get out on time, and not leave too many loose ends. I ask anyway because I simply must if I want to put the idea of an aneurysm or dissection out of my head and sleep well at night. This habit has made some colleagues and co-workers roll their eyes at the big and time consuming work-ups occasionally prompted by this practice habit, but when the tests do reveal potentially catastrophic conditions it seems to justify all the negative scans. The problem is what happens next.
Today my patient turned out to have a major dissection of her aorta, which is potentially catastrophic. It was fortunate that we caught it, but it was unfortunate that almost every hospital in the state of California was unavailable to help her. Our hospital has no thoracic surgeon to manage this condition. No hospital with a thoracic surgeon had an ICU bed where she could be admitted. After 4 hours and 30+ phone calls, I realized why many doctors don’t bother looking very hard for these things. While there is some gratification in catching a life threatening diagnosis, before it is too late, there is also tremendous negative reinforcement for this particular job well done.
For hours after my shift was over I found myself pleading with hospitals up and down the state, and wondering how full these ICU’s actually were. Were there really no beds, or simply not enough nurses. Had nurses been sent home (or not called in) to save money and as an added benefit the ICU could legally decline any transfer. Who knows. At the end of the day we did find a hospital with both an ICU bed and a thoracic surgeon. After I invested so much, and went above and beyond on my own time I hope those surgeons do the same for her. I also wonder what obstacles they may encounter attempting to do so.