Field Notes: Aortic dissections are among the scariest cases ER doctors see.
As Grant Wahl's family has correctly said, there was almost nothing anyone could have done to save him. I know they're right because I've seen so many of these cases. Here's why they are so difficult.
My first year anatomy professor Dr. Jeffrey Laitman called the aorta—the largest blood vessel in the human body—“the holy of holies.” Without it, we are nothing.
Legendary physician Dr. William Osler said that, “There is no disease more conducive to clinical humility than aneurysm of the aorta.”
More recently, the Canadian medical educator Dr. David Carr put it somewhat more directly to 21st century clinicians on the frontlines of medical care: “The Aorta Will #@&$! You Up.”
As an emergency physician, there are only a few things that make me genuinely feel a surge of adrenaline-induced panic. Among these, I can think of almost no condition that I fear more than the type A acute aortic dissection—a tearing of the lining of the initial segment (i.e. the part coming directly from the heart) of the aorta .
I am in New York City right now to attend the memorial service of Grant Wahl, who died as a direct result of a “type A” acute aortic dissection. Naturally, over the last few days, I’ve spent a lot of time thinking about Grant (though I did not know him and my connection is via his wife, my brilliant colleague Dr. Céline Gounder). Grant’s family has correctly stated, there was almost nothing anyone could have done to save him when he experienced an aortic dissection in Qatar during the World Cup. I know they're right because I've seen this condition play out far too many times in the ER.
Please join me in donating to two causes whose missions Grant and Céline shared: The Ida. B. Wells Society and The International Women’s Media Foundation.
Perhaps unsurprisingly, over the last week, I’ve found myself increasingly preoccupied with the memories of patients I’ve personally treated—or attempted to treat—with acute aortic dissections. I would not say that I exactly have P.T.S.D from these cases. However, I will say that when I think about these patients, I can literally feel—that is, my body relives the biochemical experience—of the profound sense of helplessness that so often accompanies these circumstances.
One might consider the patients whom I have diagnosed and treated for type A acute aortic dissections to be among the “luckier ones.” After all, around 40% of all patients who have this condition never even make it to an ER, dying before they get that far. For those that do make it to the hospital, depending on the location and severity of the problem and other factors, mortality rates range from 4%-24%. And as bad as that sounds (and it is) is used to be much worse.
The scary thing about aortic dissections is that they are among the most time-sensitive conditions out there. These patients can go from looking quite well—I can think of patients who were well enough to be on their cell phones to tell their family of the diagnosis—to extraordinarily unwell (unconscious and fighting for their lives) in a short period. Left untreated, mortality increases 1% per hour from the time of initial symptoms. When a patient has a type A dissection, they often need to be in the operating room immediately.
The problem is that the exact ones that need to be in the OR the soonest are also the ones who take the longest to get there, I often find. Perhaps the single biggest barrier to getting a patient from the ER to the OR is making sure they are “stable” enough to survive the short trip, usually just a few yards on a stretcher and an elevator ride.
By stable, I mean one thing: blood pressure. Now, many patients with aortic dissections have elevated blood pressures. That’s bad because with each and every heart beat with high blood pressure, the tear in the aorta worsens due to the shearing stress of blood being blasted into it. And so the goal for patients with elevated blood pressure is to lower it. That’s not that hard to achieve. But in some patients, the aortic dissection is so disruptive to the flow of blood, that the overall blood pressure becomes too low. Eventually, low blood pressure is life threatening, causing strokes and eventually leading to cardiac arrest.
The problem—and therefore the panic that I am reminded of even as I am writing this— is that treating dangerously low blood pressure caused by an aortic dissection is a double-edged sword. If we don’t raise the blood pressure, the patient may have a stroke, due to inadequate blood flow to the brain or go into cardiac arrest. But if we do raise the blood pressure, we’re at risk of making the overall situation worse, by causing that tear in the lining of the aorta to get bigger.
Deciding whether to take a patient with dangerously low blood pressure to the OR immediately or keep them in the ER a bit longer to see if we can stabilize them for the short trip, is often an impossible one, and is marked by a vicious cycle of circular logic: They’re too unstable for transport to the OR—which is the only place where the patient can possibly regain stability. If I had to guess, I’d say that we (the ER and surgical teams) probably err on keeping these patients in the ER too long. I’ve never once felt that I pushed an unstable patient with a type A aortic dissection to the OR too quickly for their own good.
Though aortic dissections are relatively rare (fewer than 200,000 per year occur in the US which means around 1 in 1,650 people), they are not unheard of. There are three categories of risk to consider. The first is existing risk factors, like Marfan Syndrome, a genetic condition that predisposes patients to tears in their blood vessels, and other connective tissue problems. The second is reported symptoms—the hallmark being a sudden severe ripping sensation in the chest and back. The third are physical findings that only clinicians would be able to reliably detect, like unusual blood pressure and pulse patterns, or distinct heart murmurs. If in doubt, seek medical attention. The sooner an aortic dissection is detected, the better the odds of survival are.
Please join me in donating to two causes whose missions Grant and Céline shared.
Field Notes: Aortic dissections are among the scariest cases ER doctors see.
Aortic Dissection diagnosis can be missed when symptoms are transient or vague e.g., Jonathan Larson, the playwright of RENT, was discharged from several NYC EDs and died at home. Aortic Dissection can present with a TIA. I recall a patient whose only sign after a 10-minute episode of focal weakness consistent with a TIA was a difference in BPs in his arms. A high index of suspicion is often needed to diagnose these situations.
The Sunday before Thanksgiving my daughter’s half brother, a 56 year old marathon biker, father of two daughters in college, had chest pain. He didn’t make it through surgery for an aortic dissection. What a nightmare.