72-year-old male presents to emergency room at 19:59 complaining of chest pain and reporting mid upper back pain, for two days getting worse today with intermittent chest tightness and shortness of breath; history of COPD.
Initial blood work ordered stat at 9:22 PM with results at 9:53 PM included a CBC and Absolute Cell at Count showing WBC slightly elevated and neutrophils at 94% and ABS neutrophils at 11.94. Also D-DIMER QUANT was 37,280 ng/mL DDU. Additional blood work which was also ordered at 9:22 PM came back at 10:18 PM which showed the following abnormal values: glucose 138; creatinine 2.22, sodium 130, CO2 19 and troponin-I of .349. The result was called to the emergency room.
A CT angiogram of the chest, abdomen and pelvis with and without contrast was ordered stat at 9:41 PM.
The imaging, which was taken at approximately 10:53 PM revealed the following:
Vessels/Heart: Type A dissection begins at the aortic root. It extends into the brachiocephalic and right common carotid arteries to thesuperior most aspect of the field-of-view. within the brachiocephalic artery, the true lumen is moderately to severely narrowed and within the visualized right common carotid artery is moderately narrowed. Right subclavian artery appears supplied by the true lumen. Left common carotid artery is supplied by the true lumen. It extends into the proximal left subclavian artery approximately 2 cm, distal to which the false lumen is no longer appreciated within the left subclavian artery. Origin of the true lumen of the left subclavian artery is moderately stenosed. Ascending aortic aneurysm measures 4.8 x 5.3 cm increased 4.6 x 4.8 cm (601:96, 602:118). Distal aorti c arch measures 3.4 x 3.6 cm, increased from 3.2 x 3.1 cm (602:89, 601:78). Mid aspect of descending aorta measures 3.3 x 3.4 cm, increased from 2.1 x 3.0 cm (602:81, 648). calcification within aortic valve. Moderate coronary artery calcified plaque. Junction between descending and abdominal aorta measures 3.1 x 3.1 cm, slightly increased from 2.9 x 3.0 cm (601:64, 602:95). Mild calcified plaque within the aortic arch and descending aorta.
IMPRESSION:
Type A aortic dissection as described. Finding discussed with Dr. Deep Desai on 6/6/2024 11:16 PM.
4.8 x 5.3 cm ascending thoracic aortic aneurysm increased from 4.6 x 4.8 cm with distal tapering, dimensions of thoracic aorta diffusely mildly increased compared with prior imaging.
New trace hemopericardium.
Stable right and new left lower lobe posterior basal segment
peribronchial thickening with mucous plugging. New bibasilar dependent atelectasis and new passive atelectasis within medial left upper and lower lobes along the descending aorta.
Thickened distal appendix measuring 9 mm in caliber without
periappendiceal induration. Early tip appendicitis is not excluded.
clinical correlation recommended. If clinically warranted,
postevacuation CT of the appendix following administration of oral contrast may be performed to evaluate for extension of oral contrast to the appendiceal tip.
Pt. PMX as taken from his Pulomonlogist's notes:
• Aneurysm of ascending aorta (CMS/HCC)
02/01/2022
suspect ascending aortic anwurysm 4.6 cm
• Aortic insufficiency 05/27/2022
• Asthma
• COPD (chronic obstructive pulmonary disease) (CMS/HCC) GERD (gastroesophageal reflux disease) 01/2023
History of 2019 novel coronavirus 02/01/2022 disease (COVID-19)
1/2027 Followed by Dr. Andrea Harangozo History of exposure to toxins via inhalation world trade center exposures
• HTN (hypertension) 05/27/2023
Multiple pulmonary nodules 11/07/2023
• OSA (obstructive sleep apnea)
Sinusitis with nasal polyps
Stage 3b chronic kidney disease
(CMS/HCC)
• Wheezing
Patient had 02 sat at 98% at 8:05 PM and 8:51 PM; dropped to 91% immediately prior to discharge and transfer at 12:51 AM.
This hospital was not able to handle the surgery and arrange for transport to a hospital that could. A Transfer Request form was filled out at 11:15 PM and it indicates that the receiving hospital agreed to accept patient at 12 o'clock midnight. By all accounts in the chart, the patient was picked up by transport at 12:53 AM.
Unfortunately, despite the fact that the thoracic surgeon indicated that there was a 70% survival rate of the surgery he was going to do, the patient came through surgery and never woke up. He passed the next day.
Was there a delay in diagnosing the dissected aortic aneurysm and, if not, was there a failure in this emergency room to more quickly transport the patient?
Files:
No questions yet!
Do you believe there might have been medical error?
Not enough detail is provided as to what exactly occurred intraoperatively and what the patient’s condition was prior to transfer. Generally speaking, this patient was transferred fairly expeditiously, considering a total of about 5 hours from initial arrival to transfer and less than two hours from the results of the CT scan.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Even if a claim of delay in transfer was sustained, with the level of information currently available, it would be difficult to clearly tie the time to transfer to the patient’s death.
What makes you a good expert for this case?
I am a senior administrative leader at a quarternary academic center who has deep experience and expertise in clinical emergency care and operations. As an EMS-boarded physician, I have in-depth knowledge of transfer policies and related regulations. Finally, I am also an intensivist who works primarily in a cardiothoracic ICU where I treat patients with aortic dissections during every shift.
How often do you encounter cases similar to this one in your practice?
I frequently diagnose and treat patients with type A aortic dissections, and also receive these patients in transfer.
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