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Right Patient, Right Place, Right Time

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     Attack One is dispatched to a midday motor vehicle accident. On scene, the crew finds a single vehicle that's run into a pole alongside a busy city street. The driver, an older male, is unresponsive on arrival, but awakens quickly when the medic asks for his name. There's a mild amount of damage to the vehicle, and the driver is held in place by a lap and shoulder belt. He is quiet but says, when asked, that his abdomen is uncomfortable. He is easily accessible through the door, and thus is immobilized quickly and brought out onto a backboard.

     A responding police officer asks to talk to one of the crew members. "Does he smell intoxicated?" the officer asks.

     "No smell or slurred speech or any other indication of that," the crew member tells him.

     The officer considers this. "I have a lady who witnessed this," he says, "who states that he was weaving down the road, and then looked like he was unconscious. Would you ask him what happened?"

     But the patient is unable to give any details. He remembers driving toward his home, then waking up in the presence of the rescue crew. He denies chest discomfort, palpitations or dyspnea. He repeats that his abdomen is uncomfortable, and says he's getting nauseated. He has not vomited, and has had neither diarrhea nor prior abdominal problems.

     The patient does, however, have a long history of hypertension, and he has had kidney stones.

     His mental status is now clear. He has a pulse rate around 60, a blood pressure of 110/70 and a respiratory rate of 18, and appears to be perfusing well.

Transportation
     The patient does not appear in great discomfort and does not meet trauma-alert criteria. Should he be taken to the nearby community hospital or the trauma center across town? This decision can be more difficult if the crew believes the man is having an acute cardiac emergency, because the interventional cardiac hospital is a third potential destination, also on the other side of town.

     The crew places the patient in the medic and quickly obtains a 12-lead EKG. If this tracing indicates an acute myocardial infarction, it will point them toward the cardiac hospital, because the presentation of syncope, nausea and vague abdominal discomfort could be explained by an acute cardiac ischemic event. The EKG, however, is normal.

     So what's left? This patient has had some type of acute medical event, then trauma (although the mechanism appears to be relatively minor), and now has abdominal discomfort. Almost apologetically, the crew calls the trauma center to give their report.

Hospital Course
     Although the trauma center is busy, the Attack One crew is greeted promptly. The patient is more uncomfortable now-due, he says, to immobilization on the backboard. He has back pain as well as the abdominal discomfort. On initial measurement in the ED, his blood pressure remains around 110/70. The ED crew, sharing the Attack One providers' suspicions of a serious problem, snaps some quick x-rays of the patient's neck and chest, draws blood and performs another 12-lead EKG. The trauma surgeon wheels in a portable ultrasound machine to check for blood in the abdomen. His attention quickly turns to the image of an aorta that is severely dilated and leaking.

     "Sir," he soon tells the patient, "we've found a significant problem in your abdomen and will need to take you into the operating room immediately."

     With that, the assembled EMS, ED and trauma personnel finish the trauma evaluation, gently remove the patient from the backboard, place a second IV line and urinary catheter, and explain the patient's problem to him. The man has no immediate family, so a chaplain assists in supporting and preparing him for the OR.

     Once there the patient is placed under anesthesia and begins to deteriorate. The surgical team intervenes rapidly and controls bleeding while finding a site to perform the repair. The patient survives and has no long-term complications. Miraculous is the term used by the surgical team. "Right patient to the right place at the right time" is how the ED crew expresses their thanks to the Attack One crew.

Case Discussion
     This patient was not critically unstable on initial presentation, but had a fatal disease process evolving that is typically difficult to identify in the field, and even in the ED. Long-term hypertension will place a strain on the walls of the aorta. Eventually the layers composing this wall can weaken, bulge and split in the abdomen or chest.

     A ruptured abdominal aortic aneurysm (AAA) results when the wall finally gives way, and the patient loses blood volume and/or suffers compromised blood flow to the abdomen or distal areas. The classic presentation includes pain in the abdomen, back or groin area. Syncope can occur, and blood in the abdomen can cause a vagal reaction, with an inappropriately slow pulse, like in this patient. It can be very easy to diagnose at the time free rupture occurs, with the patient in hypovolemic shock or cardiac arrest. The EMT will want to consider a ruptured AAA when a patient with a history of hypertension presents with abdominal, back or groin pain. Rapid surgical intervention is the only opportunity to save such a patient.

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