The Doctor Will See You Now [Non-Fiction]

Chapter 141: Acute Medicine

A 75-year-old man with a host of health issues (previous stroke, high blood pressure, severe kidney disease due to degeneration, diabetes) is admitted to us for chest pain. A chest x-ray shows an abnormality on the aorta, the biggest blood vessel coming out of the heart that feeds the rest of the body. There is a possible tear on his aorta.

This is actually known. A year ago, a CT scan for something unrelated showed a bulge on his aorta, but because of his severe kidney disease, giving him a contrast scan to better see the bulge (to see if it's an aneurysm, which is a weakening in the wall of the vessel that is at risk of bursting) will likely worsen his kidney disease making him need dialysis. He has refused dialysis already, so he would not get the CT contrast scan. His son also respects his decision and is against his dad getting surgery to patch that out-bulging even if it were an aneurysm, because it's a high-risk surgery.

Which means we can't scan him for this admission to see if that aneurysm has ruptured. He could die if it's a rupture. We can manage his blood pressure as if it's ruptured, but the mortality (death rate) for ruptured aortic aneurysms are high.

When I tell the son this, he changes his mind. He wants his dad to get the CT contrast scan. Even if it means killing his kidneys. And if it kills his kidneys, then he wants his dad to get dialysis. Even though his dad has previously refused dialysis and his son has 'respected that decision'. Asking his dad now, he replies with the vague 'Oh, I don't know. I'm not educated enough to make this decision. Ask my son.' (I get this a lot. It drives me insane.)

He could have gotten that scan a year ago to see what the bulge was and taken adequate steps to reduce its risk of rupture. He could have gotten on dialysis earlier to prolong the lifespan of his kidneys, although right now his kidney disease is severe but not yet at end stage. This could all have been planned -- and the rupture possibly avoided.

But no, because they had both refused intervention and treatment at a time before complications arose and now changed their minds when faced with the consequence of their decisions, I have to scramble to fix things again. I speak to my senior to tell him about this admission. I speak to the cardiac unit on call to get a review because this man needs aggressive blood pressure monitoring to stop the tear from progressing. I speak to ICU on call to get help for dialysis if this man needs it after a scan. I speak to the CT doctor on call to get an urgent CT scan.

After the CT is done, it shows a Type B aortic dissection, which is a ruptured aorta leading away from the heart. Treatment is usually not surgery but blood pressure control in hopes it seals itself. I speak to the surgical doctor on call just to get an opinion.

I spent six hours on this case during an on call session speaking to the many specialties involved, which could all have been avoided.