John Ritter's family suing

[Jim Henderson]

http://www.cnn.com/2004/SHOWBIZ/TV/09/09/ritter.lawsuit/index.html

Ok, this blows. A middle age guy comes in with chest pain and dyspnea.... how many of you would think "crap we need to get him to the or immediately as it is obviously an an aortic aneurism!"

I feel for the guy's family but nothing pisses me off in medicine more today than people suing over every bad outcome... if the doctors would have not done any testing and said "get a life and go back home jack tripper" that would be one thing... but doing an EKG, CXR, CBC, troponin, giving asa, o2, and whatever else is what we would all do.

I feel sorry for John's friends and family for their loss but this kind of crap drives my premiums up. It will probably get settled because if this goes in front of a lay jury, some punk lawyer in a 3000 dollar suit will tell them "it's clear... it was his aorta rupturing and the dumb ass money grubbing doctor wanted to go play golf so he did an ekg and gave him an aspirin, which probably sped up the bleed even more... nail his ass to the wall" and give John's family 20 million for financial losses, 50 million for pain and suffering, and a billion for punitive damages to the ******* doctor.!

😡 😡 😡 😡 😡 😡

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[Sessamoid]

....and give John's family 20 million for financial losses, 50 million for pain and suffering, and a billion for punitive damages to the ******* doctor.!

😡 😡 😡 😡 😡 😡

Except this is California, and non-economic damages are limited to $250,000. Granted, given he's a well-known working actor, so his potential economic damages are HUGE.

 

[Febrifuge]

"Mr. Ritter's doctors failed to properly and timely (sic) diagnose and treat an aortic aneurysm, which would have prevented his death," said Yasbeck's spokeswoman, Lisa Kasteler, in a statement."

Well, there's the issue. Civil suits rely on a couple of elements, and one of them is proving this assertion. Does anyone know the typical prognosis for someone with an AA (or was it a triple-A?) that is diagnosed more quickly?

My question is how come the hospital didn't whip out the ultrasound. We do that in all chest pain cases, unless the EKG shows evidence of a heart attack.

 

[Sessamoid]

Well, there's the issue. Civil suits rely on a couple of elements, and one of them is proving this assertion. Does anyone know the typical prognosis for someone with an AA (or was it a triple-A?) that is diagnosed more quickly?

My question is how come the hospital didn't whip out the ultrasound. We do that in all chest pain cases, unless the EKG shows evidence of a heart attack.

Transthoracic ultrasound was unlikely to catch anything in this case. You'd need a transesophageal echo to diagnose an aortic dissection. I'm not trained in that, and I doubt many EPs are. That's a procedure generally only done by a cardiologist.

The mortality for surgically treated Type I dissection is somewhere between 20-30% last I heard. That includes those with much less rapidly progressive disease than Mr. Ritter had. His dissection was apparently very rapid, resulting in his death just a little over 4 hours after presentation to the hospital. My guess is that even if the ER doc put on his x-ray glasses and said, "Aha, a Type I aortic dissection!" his mortality would still have been quite high, far higher than the 20-30% usually cited.

The median survival for such a dissection is approx 48 hours, so the vast majority of cases that make it to the ER are considerably more slowly progressive disease.

We don't know all the details of the case, so we can't make much of a guess as to its merits. However, thoracic aortic dissection is a very tough diagnosis to make unless the patient comes in with classic risk factors and a classic description of the pain. You can't just order CT angio on everybody, as it's not a completely benign procedure and rather expensive to boot.

 

[peksi]

Ritter had, as I understand, a Type A aortic dissection, which can be very difficult to identify on transthoracic echo...I know since we have the largest published data set on the ED diagnosis of this via ED US (Saw > 150 aortic dissections through our ED over 3 years). The mortality is over 30% even if treated within the first hour of symptom onset.

The reality is that this a sad event, but points to the consistent erronious view of the public that entry into the hospital system from any level, but especially the ED will mandate a perfect outcome, if this does not occur then some errored, which is rediculous!!!!...the REAL question I have, is what big gun "academic EM *****" will the lawyer hire to testify against the hospital and essentially probably a ABEM/AOBEM ED physician...is it a faculty member or residency director at your program?

This is a huge idealistic issue to me, so I pose this question. If you knew that certain faculty at your program or at a program you MS4s are are interviewing at have testified for plaintiffs in medical malpractice cases would that change your view of the program or potentially ranking that program?

Several of the largest med mal attorneys state that the majority of their expert witnesses come from "academic institutions". This type of "doctor for sale" mentality really hits to the core of the medical malpractice crisis, in that many docs especially EM physicians are willing to "sell" their opinion, I mean testimony for such cases. They cover this action with the self justification that they are "helping" victims of med mal, but in reality they are prostituting themselves, and in some sense (when speaking of the acdemic residency faculty members who do med mal like this) "raping their own children"!!


So after the diatribe I ask again, if each residency program signed something like and afadavid that residency faculty( or a percentage) had acted as a "plaintiff witness" in the past 3 years, would that be of interest to applicants?...Honestly I do believe that medical students would have the power to blunt and limit this practice of academic faculty for hire if it was seen as distainful and if disclosure by faculty was demanded by applicants!


Just a Thought


Paul

 

[docB]

This case illustrates one of the real problems with med mal. These people clearly don't need any money. They are doing this totally out of spite. Often when a family experiences a loss they feel helpless and powerless. That is a part of life and the healthy thing to do is cope and move on. With med mal these families can hang on to their grief for years and years as the case meanders through the courts and they have the illusion that they are "doing something."

 

[ERMudPhud]

If you want to read about a remarkably similar and even scarier story read about the death of Jonathan Larsen, the playwrite who wrote rent, and died of a thoracic dissection in his 20's

As for Peski's point its worth asking your faculty if they testify and if so how they choose the cases they testify in. I respect those that have the case records sent to them without knowing if the lawyer is representing the plaintiff or the defense(sometimes it is impossible not to know) and then render an opinion. Unfortunately there are plenty of hired guns out there.

 

[Sessamoid]

So after the diatribe I ask again, if each residency program signed something like and afadavid that residency faculty( or a percentage) had acted as a "plaintiff witness" in the past 3 years, would that be of interest to applicants?...Honestly I do believe that medical students would have the power to blunt and limit this practice of academic faculty for hire if it was seen as distainful and if disclosure by faculty was demanded by applicants!


Just a Thought


Paul

I would be more interested in knowing more than whether they had served as plaintiff's witness but rather what percentage of their expert witness work came from which side of the aisle. I don't begrudge people who serve as expert witnesses, but I want to know which sides of the fight they're taking.

 

[Febrifuge]

Ritter had, as I understand, a Type A aortic dissection, which can be very difficult to identify on transthoracic echo...I know since we have the largest published data set on the ED diagnosis of this via ED US (Saw > 150 aortic dissections through our ED over 3 years). The mortality is over 30% even if treated within the first hour of symptom onset.

Thanks for the info. To answer your question about malpractice, I guess I'll play another of my 'clueless pre-med' cards and ask a question back. Do applicants to programs have any already-existing mechanism for looking into staff and residents, in terms of the sort of stuff that's routinely disclosed as part of published research?

And even beyond the financial stuff... if a program was chock full of staff who also happened to serve on boards of review, if they belonged to some professional associations but not others, if they owned big shares of practice groups nearby but unrelated to that site, if they did charitable work, if they did work for either side of a med-mal case, or whatever, maybe incoming interns might have an opinion about potential effects on the educational experience, positive or negative.

I know it's another world from research, and the disclaimer about "this physician has no conflicts" is up on the screen before every presentation and lecture I sit in on... but I agree with you that it would be interesting, and maybe even important, to know more about the people whom one could be working with or training under. For my part, I suppose it would matter a little, but I think obscuring the information would matter more. On the other hand, I'm sure the expectation would be that whatever staff does when outside the staff job still adheres to a code of conduct, and can be considered irrelevant. I can't say I disagree with that either.

 

[grouptherapy]

If you want to read about a remarkably similar and even scarier story read about the death of Jonathan Larsen, the playwrite who wrote rent, and died of a thoracic dissection in his 20's

without the cash from Larsen's family's suit, rent would not have been financed

 

[ERMudPhud]

without the cash from Larsen's family's suit, rent would not be have been financed

By scary I meant the clinical story. Aortic dissection isn't high on my list when an otherwise healthy young man(he was 35 not late 20's like I said) complains of chest pain. This was in the days before CT-PE so the chance that he was going to get any imaging beyond a CXR was pretty slim. I was living in NYC at the time and I think we all thought jeez I probably would have missed that too. The sad thing for Mr. Larsen was that he was symptomatic for days and made more than one visit to the hospital so if he had been diagnosed there would have been plenty of time to operate. He apparently had unrecognized Marfans.

On a side note I knew of one of the plaintiff's witnesses (an academic EP) who supposedly testified that the dissection was clearly visible on the CXR. I knew a bunch of his residents who told me that he hardly worked any clinical shifts and that the CXR didn't look very unusual to them.

 

[grouptherapy]

my attending saw the xray and thought it was visible. they effed up

 

[peksi]

Thanks for the info. To answer your question about malpractice, I guess I'll play another of my 'clueless pre-med' cards and ask a question back. Do applicants to programs have any already-existing mechanism for looking into staff and residents, in terms of the sort of stuff that's routinely disclosed as part of published research?

This is a great question, I'm not sure they do, but it would not be unreasonable that if there was a large cry by medical students, in mass for open disclosure, a few programs may begin it and that may pressure a few to actually act on it as well.

Several physicians have "side gigs" this is not to say that you won't make money an a doc, but much like getting a mutual fund the concept is to deversify "risk". My issue is with those physicians who are willing to take a situation which clinically there is "no negligence by the EM physician" but aid in the "argument" that there was negligence in oder to make some cash!...That is my issue, it is appauling, and I bet someone will crawl out of the woodwork...or even an EM Ivory tower for the Ritter case!

I am trying to convince our EM program to consider a proactive voluntary disclosure or at least a general information paragraph to be provided to our EM residency appplicants on the percentage of faculty that provide expert witness testimony and for which side. To my knowledge, and as a member of our group's B.O.D., NONE of our physicians have provided "plaintiff" med mal testimoney...not to say that they have'nt been asked.

Paul

 

[MechE]

(or was it a triple-A?)

A triple A (AAA) is an abdominal aortic aneurism. I believe Ritter?s tear was in his aortic arch.

 

[Febrifuge]

Yes, that was my question: abdomen or aortic arch? The news reports (now that I've checked them) are saying 'thoracic' and not being more specific.

My question about ultrasound was essentially asking "...or was it the arch?" 'Cuz depending on the machine or the operator, it mmmmmight be visible.

Yes, I'm a pre-med, but now that I've said that people have started explaining stuff. So now I also might want to say I work as a tech in one of those "top" EM programs. I am phenomenally clueless about a lot, but I pay attention and try to be as smart as my mom thinks I am. I appreciate the wisdom, though, and please keep it coming. My tactic when I know jack is to stay quiet, and if I get in there a little it's when I think I know something... 😀

 

[ERMudPhud]

my attending saw the xray and thought it was visible. they effed up

He wouldn't have been an expert witness in the case would he?


The question is though, was he handed the xray and told that the patient died of a dissection and then asked if he could see it or was he just asked if he saw anything on the xray. That is one problem with expert testimony is that it is all done through a retrospectoscope. I assume since he was seen in two hospitals and went days without being diagnosed that the dissection was also not noted by the attending radiologist who eventually read the film. So, it may not have been too obvious.

 

[DrMom]

retrospectoscope

I hear that you can get one of these pretty cheap on ebay.

 

[spyderdoc]

Yes, that was my question: abdomen or aortic arch? The news reports (now that I've checked them) are saying 'thoracic' and not being more specific.

My question about ultrasound was essentially asking "...or was it the arch?" 'Cuz depending on the machine or the operator, it mmmmmight be visible.

Yes, I'm a pre-med, but now that I've said that people have started explaining stuff. So now I also might want to say I work as a tech in one of those "top" EM programs. I am phenomenally clueless about a lot, but I pay attention and try to be as smart as my mom thinks I am. I appreciate the wisdom, though, and please keep it coming. My tactic when I know jack is to stay quiet, and if I get in there a little it's when I think I know something... 😀

I had an interesting one a few months back where I put the U/S probe on to look at the abdominal aorta, and I could see the dissection flap that was travelling from the root to the iliacs...

Another point, the TEE may miss a tear that is in the arch because of the blind spot created by the air in the trachea...It is also nearly impossible for us to get a TEE in our ER, so if we suspect it, the patient gets a CT...

 

[Sessamoid]

I had an interesting one a few months back where I put the U/S probe on to look at the abdominal aorta, and I could see the dissection flap that was travelling from the root to the iliacs...

Another point, the TEE may miss a tear that is in the arch because of the blind spot created by the air in the trachea...It is also nearly impossible for us to get a TEE in our ER, so if we suspect it, the patient gets a CT...

I had one guy in residency that I found a huge ruptured AAA by my U/S. No mistaking it, but the surgical resident insisted on getting a "formal ultrasound" anyway. The guy died on the operating table.

It wasn't subtle. 17 cm by the u/s tech's measurement (I got 15 cm). I turned on the doppler and there was obvious flow outside both the true and false lumens.

 

[peksi]

I had one guy in residency that I found a huge ruptured AAA by my U/S. No mistaking it, but the surgical resident insisted on getting a "formal ultrasound" anyway. The guy died on the operating table.

It wasn't subtle. 17 cm by the u/s tech's measurement (I got 15 cm). I turned on the doppler and there was obvious flow outside both the true and false lumens.

Yes some signs of Rupt AAA and on occasion a dissecting flap can be seen, but it is tough to see a dissecting flap at the level of the aortic root, in the distal thoracic and abdominal arta the sensitivity is better. here is what we have don.


The simple fact is the lack of these findings CANNOT fully exclude these entities, therefore, if there is a AAA on ED US and rupture is suspected,--pt directly to OR or CAT in some hospitals.

As for Aortic dissection, not all dissections go to the OR, not even all proximal thoracic dissections go to the OR, as the data does not show improved morbid/mortality UNLESS ther is 1. a pericardial effusion (can see on ED US), 2. Aortic Insuffieciency (may see on ED US but generally occurs if Aortic root is greater than 5 cm-can see this on ED US), Evidence of AMI (ECG), or 4. The patient is hypotentsive. 5. Extension of dissection to carotids


Paul

 

[juddson]

OK, I have a few questions. Some of these might have been answered above - but I'm getting conflicting information?

1) As I understand it, Ritter went in less than four hours. Would that be considered "rapid". If so, would that also suggest a "profound" dissection rather than a minor one?

2). Irrespective of the type of imaging used, are "profound" dissections easier to see than minor ones?

3). Is it possible that a profound Type A dissection would be visible on a transthoracic echo? What about film?

4). From what you know about he Ritter case, is there something that suggests to you that US was NOT indicated? What about film?

Help me out here.

Judd

 

[FoughtFyr]

OK, I have a few questions. Some of these might have been answered above - but I'm getting conflicting information?

1) As I understand it, Ritter went in less than four hours. Would that be considered "rapid". If so, would that also suggest a "profound" dissection rather than a minor one?

2). Irrespective of the type of imaging used, are "profound" dissections easier to see than minor ones?

3). Is it possible that a profound Type A dissection would be visible on a transthoracic echo? What about film?

4). From what you know about he Ritter case, is there something that suggests to you that US was NOT indicated? What about film?

Help me out here.

Judd

The question is "does it matter?" He died on the table. An ascending aortic rupture is catastrophic, even if surgical invention is performed. Seeing as he made it to the table, and died anyway, my question is simply, would the added time have made a difference? The overall time frame was rapid, given that even once the dissection is recognized, some time will elapse before surgery can begin. The sedation process, and neurohormonal release that accompanies surgical resection could have also been problematic. There is nothing I can see that suggests, given he died in surgery, he would have survived at all. Remember, there is a ~30% mortality from the procedure alone...

- H

 

[Skip Intro]

Begging everyone's pardon here, but you guys are talking about a lot of fancy tests (TEE, etc.). And, as I'm currentlly in the midst of studying for Step 2, I can tell you that this is pretty basic stuff and it's ALL OVER the boards.

Clinical judgment is still paramount. We can't rely on machines to think for us. If we're talking a very high rupture here (someone mentioned a DeBakey I or II/Stanford A, although I'm not sure where that info came from), what about simple stuff first? If you're tearing into the arch, you're probably tearing into the coronary arteries (which is a death sentence, granted), but you don't start with the $1M work-up anyway. You check the BP in each arm... is there a disparity? You look at the simple, routine x-ray... is the mediastinum widened? You look at the EKG for characteristic changes. You put a stethoscope to the chest and listen. These are simple things. Do you think DeBakey had a TEE back in 1954 when he was cracking chests and fixing these for the first time? 🙄

It appears that grouptherapy already nailed it: his attending saw the CXR and the ER docs f***ed up.

Now, the bigger question (and it's sad that they are suing, I agree) is whether or not they did these simple tests in time, confirmed the diagnosis, and got him to the table as quickly as possible. We don't know any of these things, of course, but the cause of the purported "misdiagnosis" cannot be blamed on lack of access to fancy machines.

It could be that the tear was just too massive to fix. If that's the case and, more importantly, the jury buys it, then there is no case. It wouldn't have made a difference. Chances are, the hospital will probably settle no matter what was done, right or wrong, just to put this past them.

Sadly, that's the state of medicine today: we don't rely (or don't think to use) basic clinical judgment because we fear if we don't do the million dollar tests (e.g., TEE, troponin markers [which take time], etc.) we'll get sued... damned if you do, damned if you don't in this case. Yes, medicine is really screwed up right now.

-Skip

 

[Sessamoid]

1) As I understand it, Ritter went in less than four hours. Would that be considered "rapid". If so, would that also suggest a "profound" dissection rather than a minor one?

It's very rapid. "Profound" is not an adjective one would use to describe an aortic dissection.

2). Irrespective of the type of imaging used, are "profound" dissections easier to see than minor ones?

Well, not "profound". But larger dissections are easier to see on any kind of radiographic imaging. The size of the thing doesn't necessarily exactly correlate to the danger of a dissection. A small dissection can be just as fatal if it's in the wrong place.

3). Is it possible that a profound Type A dissection would be visible on a transthoracic echo? What about film?

It's debatable. Maybe yes, maybe no. Aortic dissections are very difficult to diagnose on a plain chest x-ray, largely because of it's rarity. Rare diseases lead to low suspicion in the mind of the clinician. Even with a retrospectoscope, you often have to use your imagination a little to see it. Very few disections are obvious on chest x-ray.

4). From what you know about he Ritter case, is there something that suggests to you that US was NOT indicated? What about film?

TTEs are not common in the ED. I've seen exactly one done in the ER. The question in this case will be whether there were any clues that could have led the physicians to somehow differentiate Ritter's case from the many other cases of chest pain that come in every day in every ER in the country.

Hope that helps.

 

[Seaglass]

Do you think DeBakey had a TEE back in 1954 when he was cracking chests and fixing these for the first time?

No, he had the luxury of holding a dead person's obviously dissected aorta in his hands.

 

[Sessamoid]

Clinical judgment is still paramount. We can't rely on machines to think for us. If we're talking a very high rupture here (someone mentioned a DeBakey I or II/Stanford A, although I'm not sure where that info came from), what about simple stuff first? If you're tearing into the arch, you're probably tearing into the coronary arteries (which is a death sentence, granted),

Who said anything about tearing into the arch? You're assuming data you don't know the truth of. You can tear into the arch without occluding the carotids, btw.

but you don't start with the $1M work-up anyway. You check the BP in each arm... is there a disparity?

If you order blodo pressures in both arms on every patient you see, you'll quickly find nurses who won't work with you. You also don't know that they didn't check it in this case.

You look at the simple, routine x-ray... is the mediastinum widened?

Do you know how insensitive a widened mediastinum is for aortic dissection?

You look at the EKG for characteristic changes.

Unless the coronary arteries are occluded, there won't be any. Also insensitive.

You put a stethoscope to the chest and listen. These are simple Where you will hear exactly what in a busy ER?

Do you think DeBakey had a TEE back in 1954 when he was cracking chests and fixing these for the first time? 🙄

I'm a little unimpressed by a student studying for his preclinical board exam rolling his eyes at practicing physicians.

It appears that grouptherapy already nailed it: his attending saw the CXR and the ER docs f***ed up.

I guess I know who the plaintiff's lawyers will be calling to sue honest physicians in the future.

Skip, get some experience and get back to us.

 

[Seaglass]

As Sessamoid says, except at places with HIGHLY developed ED US programs (e.g. Christiana and Peski's domain) TTE takes a long time to get and even longer for TEE. Here at Wake it's going to take at least an hour for TTE and probably 4-6 for TEE. Even if you can convince the fellow it's an emergency it will take at least an hour for TEE I would say.

As for blood pressures, murmurs, CXR, they all have such a low sensitivity as to be more or less useless unless grossly positive.

but the cause of the purported "misdiagnosis" cannot be blamed on lack of access to fancy machines.

Oh yes, yes it can. Do you really think DeBakey caught 100% of dissections with his physical exam acumen?

 

[Sessamoid]

Oh yes, yes it can. Do you really think DeBakey caught 100% of dissections with his physical exam acumen?

No, DeBakey's reputation was so powerful that the dissections would quaver in abject fear, then announce their presence to the world. No diagnostic testing needed at all!

 

[Skip Intro]

Who said anything about tearing into the arch? You're assuming data you don't know the truth of. You can tear into the arch without occluding the carotids, btw..

Of course you can. Where did I say otherwise? We don't know where exactly he tore, except that it was severe enough to have him pronounced dead within four hours of his arrival at the hospital.

If you order blodo pressures in both arms on every patient you see, you'll quickly find nurses who won't work with you. You also don't know that they didn't check it in this case.

Well, you don't reach for the TEE on every patient either, do you? And, which is more cost effective, checking the blood pressure in the opposite arm or a TEE? Which will get a faster result in your hands?

Do you know how insensitive a widened mediastinum is for aortic dissection?

In light of the other findings, more sensitive than as a stand alone test. Someone mentioned that they saw a widened mediastinum on the CXR. Now, doctor, a more important question is what would you think if a patient came in with severe chest pain and a widened mediastinum?

Unless the coronary arteries are occluded, there won't be any. Also insensitive.

Right, so you have severe, unremitting chest pain in the presence of no focal ECG changes, and in light of a widened mediastinum on a chest x-ray. Are you waiting for a sonographer to come in to do a TEE or are you wheeling the patient to the OR at this point? That's a fair question.

Don't get me wrong, Sessamoind. I pretty much totally agree with what you're saying here. I, along with just about everyone else participating in this thread, have no idea what was done. I do know, however, that most ER's don't have the luxury of having someone running a TEE in their ER. And, when you start adding the symptomolgy together, you get a clinical picture. That's the point. All of these tests together will start to point you in the right direction (i.e, chest pain, perhaps tearing and radiating to the back [don't know if that was asked or not either], plus maybe equivocal ECG changes, plus a widened mediastinum on x-ray... you start to get a flavor and work in a certain direction, especially if your previous differentials aren't adding up with the tests you've already run...). Even a fourth-year medical student (like myself) has learned that much already. Or, as a self-proclaimed practicing physician, do you disagree with that? My point is, if you start to smell a fish do you wait until you can get someone to do a TEE before you cut? I definitely recognize the dilemma. That was the bigger point, if you re-read my post, that I was trying to make. And, from all of my teaching so far, I don't think picking up a dissection aortic aneurysm has been impressed upon me as a huge diagnostic dilemma if you're paying attention. Or, do you disagree doctor?

I'm a little unimpressed by a student studying for his preclinical board exam rolling his eyes at practicing physicians.

Well, technically Step 2 is not "pre-clinical" and I've been in the clinic for over a year already, but... hey, I'm not trying to step on your toes. The thing is, sometimes stuff is fresher when you've just picked up the book and read, I'm not faulting anyone here. The doctors and nurses didn't give Ritter an aneurysm. I have no idea if a mistake was made or not. Sounds like this was a catastrophic tear, him dying so fast and all. Who the hell knows what really happened? That was not my point at all.

Skip, get some experience and get back to us.

Roger that. But, I hope you're not inferring that I'm the only one who can learn something from this...

-Skip

 

[Sessamoid]

I totally agree with what you're saying here.

Then perhaps you should change your tone. You're not in the medical student forum here. You came in here and took a haughty attitude, then proceeded to lecture to a group of emergency medicine residents and attendings about thoracic aortic aneursyms. More than a little presumptuous.

Phrases like "the ER docs f***ed it up" will not earn you any friends here. BTW, the x-ray they were talking about wasn't re: the case of John Ritter. The fact that you are willing to say somebody "f***ed up" based on the hearsay of somebody you don't know who says his attending saw the x-ray after the fact after already knowing the diagnosis is offensive to me and, I suspect, to others here.

And, from all of my teaching so far, I don't think picking up a dissection aortic aneurysm has been impressed upon me as a huge diagnostic dilemma if you're paying attention. Or, do you disagree?

How many chest pain patients do you treat a day? All the physical findings associated with thoracic dissections are poorly sensitive. You're supposed to be "fresher" on this than us old guys, so you should know that. It is a dilemma because it's a dangerous but rare disease with no sensitive/reliable physical findings. The one ascending dissection I've diagnosed newly had chest pain as the only complaint and absolutely no physical findings whatsoever aside from being kind of a tall guy. As you will hear often in your training in the future, "Patients don't read the textbooks."

Well, technically Step 2 is not "pre-clinical"

Step 1 had clinical information in it too, but that doesn't make it a clinical exam. Step 3 is first board exam you will take that requires that you be a practicing physician. That's my definition of a clinical board exam.

 

[mikecwru]

Then perhaps you should change your tone. You're not in the medical student forum here. You came in here and took a haughty attitude, then proceeded to lecture to a group of emergency medicine residents and attendings about thoracic aortic aneursyms. More than a little presumptuous.

Phrases like "the ER docs f***ed it up" will not earn you any friends here. BTW, the x-ray they were talking about wasn't re: the case of John Ritter. The fact that you are willing to say somebody "f***ed up" based on the hearsay of somebody you don't know who says his attending saw the x-ray after the fact after already knowing the diagnosis is offensive to me and, I suspect, to others here.


How many chest pain patients do you treat a day? All the physical findings associated with thoracic dissections are poorly sensitive. You're supposed to be "fresher" on this than us old guys, so you should know that. It is a dilemma because it's a dangerous but rare disease with no sensitive/reliable physical findings. The one ascending dissection I've diagnosed newly had chest pain as the only complaint and absolutely no physical findings whatsoever aside from being kind of a tall guy. As you will hear often in your training in the future, "Patients don't read the textbooks."


Step 1 had clinical information in it too, but that doesn't make it a clinical exam. Step 3 is first board exam you will take that requires that you be a practicing physician. That's my definition of a clinical board exam.

Think of this on the flip side. You had a guy that was overweight, hypertensive, with other cardiac risk factors coming in with chest pain. Did he say the pain was radiating to the back? He could have said that he was hurting substernally or in the left chest without any radiation and clinically looked like an MI. If you're hedging your bets on the more likely diagnosis, a diagnosis where treatment is time sensitive, it becomes a little harder to fault the ER doctors. Just to be safe, the ER doctor checks a portable chest xray, looks at it, and judges the mediastinum to not be wide, or more importantly, the CXR to look fairly normal. The prelim read on the xray is the same. The patient has equal pulses x 4 extremities, normal pupils and neuro exam. I would have given the the same treatment and would have probably heparinized him (killing him even quicker). It's hard to guess at this if you don't know the details.

And the guy whose attending saw the Xray: how did he see it? Where did he get access to it? There's a big difference between "Look at John Ritter's xray: do you see anything wrong?" with "look at this undifferentiated xray and pick out any abnormalities."

I would suspect that almost all ER doctors were paranoid about an aortic dissection in the DDX long before Ritter croaked.

mike

 

[Jim Henderson]

9 out of 10 docs in the country would have "misdiagnosed" this initially. Board exams may make this easy, but our experience in the ER will say "chest pain" with ekg changes and the ddx would have aortic disection way, way down the list in probable diagnoses.

I got shoved into a small town ER by myself with only backup attending staff in the second and third year of residency and we did not have an echo available in the ER.

Most people on this board claiming that the "er docs blanked it up" and probably the attending who said this, would have been named in this shotgun lawsuit because in all likelyhood they all would have missed it and even if they did not the guy would be dead.

We don't have to get angry with each other but it should serve as a humbling case to those in med school.... you will get sued.... most of the time for something non-catastrophic that you never gave a second thought.... if there is a bad outcome you will get sued no matter how good of job you did.

Bottom line is 9/10.... 9/10 docs would think CAD in Ritter upon arrival... probablly 999/1000 more likely. If you didn't think CAD / MI, then you'd be sued for all of those cases you wasted your time getting an echo, bp on each arm, tee, etc...

It is a no win situation, except for the Lexus and Hummer dealers near Ritter's family and their $3000 Italion suit lawyer who probably lives in a mansion or whose office is one (and for the doc who ****** himself to this lawyer to testify in this case.)

 

[southerndoc]

Clinical judgment is still paramount. We can't rely on machines to think for us. If we're talking a very high rupture here (someone mentioned a DeBakey I or II/Stanford A, although I'm not sure where that info came from), what about simple stuff first? If you're tearing into the arch, you're probably tearing into the coronary arteries (which is a death sentence, granted), but you don't start with the $1M work-up anyway. You check the BP in each arm... is there a disparity? You look at the simple, routine x-ray... is the mediastinum widened? You look at the EKG for characteristic changes. You put a stethoscope to the chest and listen. These are simple things. Do you think DeBakey had a TEE back in 1954 when he was cracking chests and fixing these for the first time? 🙄

Where I'm training, we have a philosophy that if you criticize someone's medical judgment or treatment, you should have the studies to back up what you're saying.

So, please provide us all with the sensitivity and specificity of unequal blood pressures, widened mediastini in portable chest x-rays, and EKG changes associated with dissections. You mention a stethoscope, so why not quote us the number that have associated murmurs?

Thanks for educating us. We have a philosophy that serves us well: you don't criticize without educating.

 

[spyderdoc]

Another possible scenario: Perhaps the ER doc recognized the dissection due to symptoms and exam, then called ST surgery, who may have said, "I am not going to cut open this movie star unless I have absolute confirmation that this is a dissection. Hence the long wait for confirmatory studies..."
Sounds like a more plausible explanation to me given that nowadays, they won't even take an obvious appy to the OR without the CT...
Everyone just points straight to th ER doc before all the facts are known.
Respectfully,
Mark

 

[FoughtFyr]

It appears that grouptherapy already nailed it: his attending saw the CXR and the ER docs f***ed up.

-Skip

Actually Skip, you just f***ed up. grouptherapy was talking about the case of Jonathan Larsen, "the playwrite who wrote rent, and died of a thoracic dissection in his 20's."

See how easy it is to overlook small details in your rush to judgement?

Maybe you should try law school. If you miss small details there, no one dies, you just put another doctor out of business.

- H

 

[Skip Intro]

Actually Skip, you just f***ed up. grouptherapy was talking about the case of Jonathan Larsen, "the playwrite who wrote rent, and died of a thoracic dissection in his 20's."

You're right. Sorry, about that one. It was late last night when I posted, and I scanned and misread.

We have a philosophy that serves us well: you don't criticize without educating.

Well, pardoning your obvious sarcasm, I agree with this sentiment. So, here goes...

No one had mentioned a helical CT up to the point I posted, which is available at most big institutions now, is faster than a TEE, and could've been done if/when suspicion arose about Ritter's condition. Granted, this isn't a clinical test.

Helical computed tomography (CT) allows diagnosis of acute aortic dissection with a sensitivity and specificity of nearly 100%.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9925391

Again, I wasn't there and don't know if he presented like a "textbook" or not. He had been having pains all day long... I'm sure it's reasonable to think that he was having a horse and not a zebra. I'm still looking for sens/spec for combined symptomology. If I find it, I'll post.

Thanks to you all for your... ahem... "constructive" criticism. Playing devil's advocate, I guess, requires that you're willing to take the slings and arrows of those who feel they've been trampled upon.

-Skip

 

[Skip Intro]

Another possible scenario: Perhaps the ER doc recognized the dissection due to symptoms and exam, then called ST surgery, who may have said, "I am not going to cut open this movie star unless I have absolute confirmation that this is a dissection. Hence the long wait for confirmatory studies..."
Sounds like a more plausible explanation to me given that nowadays, they won't even take an obvious appy to the OR without the CT...
Everyone just points straight to th ER doc before all the facts are known.
Respectfully,
Mark

Yeah, I totally agree. It's wrong to "blame" anyone without the facts. As I already said, sometimes you're damned if you do, damned if you don't. I have no idea, just as everyone else, specifically how John Ritter presented when he presented at the ER. So, I'm not "blaming" anyone. Again, the ER docs didn't cause his dissection. And, having seen patients camped out in an ER for days, four hours doesn't seem like a long time while they're running tests. I'd be willing to bet that he got the VIP treatment while he was there too.

Also, I did find this from JAMA (my bolding for emphasis)...

CONTEXT: Acute aortic dissection is a life-threatening medical emergency associated with high rates of morbidity and mortality. Data are limited regarding the effect of recent imaging and therapeutic advances on patient care and outcomes in this setting. OBJECTIVE: To assess the presentation, management, and outcomes of acute aortic dissection. DESIGN: Case series with patients enrolled between January 1996 and December 1998. Data were collected at presentation and by physician review of hospital records. SETTING: The International Registry of Acute Aortic Dissection, consisting of 12 international referral centers. PARTICIPANTS: A total of 464 patients (mean age, 63 years; 65.3% male), 62.3% of whom had type A dissection. MAIN OUTCOME MEASURES: Presenting history, physical findings, management, and mortality, as assessed by history and physician review of hospital records. RESULTS: While sudden onset of severe sharp pain was the single most common presenting complaint, the clinical presentation was diverse. Classic physical findings such as aortic regurgitation and pulse deficit were noted in only 31.6% and 15.1% of patients, respectively, and initial chest radiograph and electrocardiogram were frequently not helpful (no abnormalities were noted in 12.4% and 31.3% of patients, respectively). Computed tomography was the initial imaging modality used in 61.1%. Overall in-hospital mortality was 27.4%. Mortality of patients with type A dissection managed surgically was 26%; among those not receiving surgery (typically because of advanced age and comorbidity), mortality was 58%. Mortality of patients with type B dissection treated medically was 10.7%. Surgery was performed in 20% of patients with type B dissection; mortality in this group was 31.4%. CONCLUSIONS: Acute aortic dissection presents with a wide range of manifestations, and classic findings are often absent. A high clinical index of suspicion is necessary. Despite recent advances, in-hospital mortality rates remain high. Our data support the need for continued improvement in prevention, diagnosis, and management of acute aortic dissection.

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=10685714

So, the patient may not present "classically" (obviously), but I still can't help to see that the article concludes that the clinician's "spidey sense" has to be tunned in and thinking about dissection. I'm not saying that it wasn't in this case; they obviously correctly diagnosed him and had him on the table within four hours.

The real question is, was that reasonable? Sadly, that's now for the lawyers, the judge, and the jury to decide.

🙁

-Skip

 

[Skip Intro]

One last thing about things being "fresh" in the mind, from Harrison's Online (you need a subscription)...

A second commonly used cognitive shortcut, the availability heuristic, involves judgments made on the basis of how easily prior similar cases or outcomes can be brought to mind. For example, the experienced clinician may recall 20 elderly patients seen over the past few years who presented with painless dyspnea of acute onset and were found to have acute myocardial infarction. The novice clinician may spend valuable time seeking a pulmonary cause for the symptoms before considering and discovering the cardiac diagnosis. In this situation, the patient's clinical pattern does not fit the expected pattern of acute myocardial infarction, but experience with this atypical presentation, and the ability to recall it, can help direct the physician to the diagnosis.

Errors with the availability heuristic can come from several sources of recall bias. For example, rare catastrophes are likely to be remembered with a clarity and force out of proportion to their value, and recent experience is, of course, easier to recall and therefore more influential on clinical judgments.

http://harrisons.accessmedicine.com...ed/harrisons/co_chapters/ch003/ch003_p02.html


This article discusses heuristics, which are exploratory problem-solving techniques that utilize self-educating techniques to improve performance, as a way that clinicians think through problems. It could be that recent, common experience directed the clinicians into thinking that atypical MI was more likely. Who knows? And, moving forward, this "catastrophe" may bias them into thinking that their differential in atypical presentations should more heavily weigh in favor of aortic dissection in the future. Again, who knows for sure?

Point is, we're human. We need to rely on our clinical judgment first and foremost. And, yes, we're prone to making errors... not that one was necessarily made in this case. Is this reasonable? Well, it's at the very least a fact of life.

-Skip

 

[FoughtFyr]

You're right. Sorry, about that one. It was late last night when I posted, and I scanned and misread.
-Skip

I hope it is not "late" when your patients come in or else I'm sure there will be an M3 somewhere, on an online forum, waiting to second guess your decision making.

- H

 

[Skip Intro]

I hope it is not "late" when your patients come in or else I'm sure there will be an M3 somewhere, on an online forum, waiting to second guess your decision making.

- H

M4, and John Ritter presented to the ER at around 6:00 PM.

-Skip

P.S. Nice use of the "arrogant doctor" persona, though. You seem to have that down pat. Congratulations for you.

 

[southerndoc]

Well, pardoning your obvious sarcasm, I agree with this sentiment. So, here goes...

No one had mentioned a helical CT up to the point I posted, which is available at most big institutions now, is faster than a TEE, and could've been done if/when suspicion arose about Ritter's condition. Granted, this isn't a clinical test.

I agree that CT is an excellent tool in diagnosing aortic dissections, but your previous post made reference to unequal blood pressures, EKG changes, and a widened mediastinum on chest x-ray. So do you have this data available or not?

You made reference that DeBakey didn't have TEE's available during his time. I don't think he had CT either.

So what is the sensitivity and specificity of the tests you mentioned?

 

[Skip Intro]

So what is the sensitivity and specificity of the tests you mentioned?

Well, if you'd have read further, you'd have seen that I presented some data. But, I don't know if that specific of a study as you suggest has actually ever been done (may or may not have been, and I may not have access to it). Either way, it's not an excuse to ignore clinical signs and jump right to the million-dollar work-up. Anyway, maybe this is a good research project for you during your residency...

You made reference that DeBakey didn't have TEE's available during his time. I don't think he had CT either.

I think that's the whole point. But, maybe a bigger question (one that, granted, can never be answered) is how many dissections did DeBakey and his colleagues miss...


-Skip

 

[Sessamoid]

M4, and John Ritter presented to the ER at around 6:00 PM.

-Skip

P.S. Nice use of the "arrogant doctor" persona, though. You seem to have that down pat. Congratulations for you.

At my hospital, by 6pm I'm likely the only physician in the house. Definitely all the cardiologists are gone for the day, though the radiologist may still be around. That qualifies as "late" for me. CT surgery? Heh, not a chance.

 

[southerndoc]

Well, if you'd have read further, you'd have seen that I presented some data. But, I don't know if that specific of a study as you suggest has actually ever been done (may or may not have been, and I may not have access to it). Either way, it's not an excuse to ignore clinical signs and jump right to the million-dollar work-up. Anyway, maybe this is a good research project for you during your residency...

Unfortunately my time is already consumed with research projects I have in place now.

Hopefully the below data will help you. The clinical signs you mentioned can be quite sensitive and specific to aortic dissections.

Chest X-rays: When physicians were given chest x-rays of dissections and not told of this, they characterized 93% as abnormal. However, only 73% were recorded as suspicious for aortic dissection. Only 38% of dissection chest x-rays had a widened mediastinum by one study(1), but another study reported up to 90% of all dissections had a widened mediastinum(2). Another study demonstrated that the probability of dissection with a widened mediastinum was 39%.(2) See below for how this correlates with coupling with clinical signs.

Clinical signs: Pulse and blood pressure differentials between the arms has been characterized as up to 100% sensitive for aortic dissection and 92% specific. 38% of individuals presenting with aortic dissection have unequal pulses. Mediastinal widening when coupled with classic aortic pain (sharp, tearing, migratory) increases the probability of dissection to 83%. Mediastinal widening, when coupled with blood pressure differentials was shown to be 100% predictive of dissection. Only 4% of acute aortic dissections present with ECG findings.(2)

One study (2) calculated odds ratios for various signs indicative of dissection. Among them were immediate onset of pain (8.59 OR), tearing or ripping pain (26.49), migratory pain (12.78), pulse and/or blood pressure differentials (75.05), and mediastinal and/or aortic widening (11.01).

So, you are correct in that a careful history, physical exam, and chest x-ray should clue you in to the possibility of a dissection. I cannot comment on Ritter's case because I do not know how he presented. For all I know, he might have described his pain as pressure that started gradually, doesn't migrate, and he might have had equal blood pressures in each arm.

1: Gregorio, MC, et al. The presenting chest roentgenogram in acute type A aortic dissection: a multidisciplinary study. Am Surg 2002, 68(1):6-10.

2. von Kodolitsch, Y, et al. Clinical prediction of acute aortic dissection. Arch Int Med 2000, 160:2977-2982.

 

[FoughtFyr]

P.S. Nice use of the "arrogant doctor" persona, though. You seem to have that down pat. Congratulations for you.

"Arrogant doctor" persona, nope. Realistic after a bit of experence, yep. It is extremely easy, in retrospect, to second guess what happened; when we simply don't know. First, do not forget that he did die in surgery, so at some point the correct dianosis was realized. Second, understand that the time it took you to read and erroneously respond to the previous post is about the time the ED (and BTW it is "ED" around these parts, our departments have many rooms) doctor had to make a desicion. Faced with CP and increased risk factors, he/she likely said something to the effect of "well it is probably a heart attack, but we will run some tests to be sure." When the tests, whichever they were, that led to the final and correct dianosis were in, then arrangements were made for surgery. Four hours door-to-knife, less than ideal but not unrealistic in many facilities.

BTW - rule #46 - There is no such thing as a textbook case - illnesses don't read textbooks.

rule #47 - Everyone's a professional quarterback on Monday morning.

Have fun in your career, I hope that you find some good mentors who will live up to the high standards you seem to have set for yourself.

- H

 

[Skip Intro]

When the tests, whichever they were, that led to the final and correct dianosis were in, then arrangements were made for surgery. Four hours door-to-knife, less than ideal but not unrealistic in many facilities.

Well, this is a straw man, and likewise nowhere in any of my posts did I attempt to argue otherwise (if you'll go back and carefully re-read).

So, you are correct in that a careful history, physical exam, and chest x-ray should clue you in to the possibility of a dissection. I cannot comment on Ritter's case because I do not know how he presented. For all I know, he might have described his pain as pressure that started gradually, doesn't migrate, and he might have had equal blood pressures in each arm.

Thanks for the info, southerndoc. This is really all I was getting at. Likewise, I didn't mean to offend anyone, but I'm still a little disappointed that some people took my first post on this thread in such an inflammatory way, and then felt the need to try to put me in my "place". (That says more about your attitudes than it does mine... you know who you are.)

As I've said all along, I don't have any clue what the specifics were in the Ritter case either, along with everyone else. To me - seeing what I've seen already as a lowly 4th year student and, not to mention the fact that I worked for two years in an ER in Miami (or ED... or casualty ward... or A/E Department... for the pedants), four hours doesn't seem all that unreasonable to me either. And, it's really hard to say - not knowing the facts - if moving any faster would've made a difference anyway. But, the entire point of why I posted was to say that running for expensive, not routinely available tests, as was suggested, certainly wouldn't have made them come to the diagnosis any faster. It's a clinical diagnosis mostly; tests are only confirmatory. Nothing anyone has said or posted since my first post disagrees with that.

The undisputed facts as I see them are (1) Ritter died on the operating table of a massive aortic dissection, (2) he was ultimately appropriately diagnosed in what appears to be a not-necessarily-unreasonable amount of time, and (3) the staff at the hospital certainly didn't cause the dissection.

Sadly, in our litigious society, families along with aggressive medmal lawyers feel that someone has to be responsible, and the finger of blame goes to the hospital and the doctors. For anyone who read what I posted and inferred anything other than that from what I said, I hope that clears up any confusion for you.

Anyway, it's all good. 😎

-Skip

 

[ERMudPhud]

Begging everyone's pardon here, but you guys are talking about a lot of fancy tests (TEE, etc.). And, as I'm currentlly in the midst of studying for Step 2, I can tell you that this is pretty basic stuff and it's ALL OVER the boards.
-Skip

This is probably the sentence that started to get everyone upset because even if it is basic and all over the boards it isn't simple or basic in real life. On the boards if they give you a dissection case it will have unequal pulses and a widened mediastinum because that is how standardized tests work.

Unfortunately, the data southern doc gave you is mostly positive predictive values or specificities. I have not doubt that tearing sudden pain with a wide mediastinum, and unequal pulses has a PPV approaching 100% but what we want in the ED to rule out a life threatening disease is sensitivity or negative predictive values (not quite the same thing) and none of the screening studies you mention even comes close and most sensitivities I've seen quoted fall well below 50%. So if you are worried about dissection you need to jump quickly to the gold standard test. So in the ideal setting a chest pain patient gets a quick ekg and cxr because you may get an answer there that you can do something about. Even if his mediastinum looked a little funny or his pulses (which I wouldn't bother checking) were a little off you would have a hard time getting the OR team and CT surgeon called in for no other reason than even with a proven dissection not all dissections go to the OR. If you don't get a definitive answer from ekg and cxr then you have to decide how high is dissection on your list. If it is high you get the CT or maybe a TEE and then call the surgeon if you've got a surgical dissection. In my hospital at 6:00 pm I could easily have 6-8 people waiting for 2 CT scanners. I have to triage based on how sick they are and how sick they might be. The hospital I work in now is about as efficient as any of the dozen or so hospitals I've ever worked in. Assuming a patient gave me a good story for a dissection and there was no one more critical in front of them for the scanner I could probably manage door to triage to bed to IV and bloods drawn to exam to ekg to cxr to CT scanner to results to OR in something between 1-2 hours. However a couple of hypotensive belly pains or a head injury with declining mental status and I would say I see tons of chest pain with normal cxr's and normal exams so he can wait while the head injury and the old lady with belly pain get scanned.

The most important lesson you can get from all this is that if you are worried about dissection don't let a normal cxr and normal pulses and normal ekg stop you from getting the CT. Also, just for fun take bilateral BP's on the next 100 patients you see and record how many have a SBP differential >15 and how many have dissections. If you are seeing the typical American middle age to geriatric population a good number will have differential BP's but no dissection

 

[margaritaboy]

And, as I'm currentlly in the midst of studying for Step 2, I can tell you that this is pretty basic stuff and it's ALL OVER the boards.

😱

Do you think DeBakey had a TEE back in 1954 when he was cracking chests and fixing these for the first time? 🙄

😱

his attending saw the CXR and the ER docs f***ed up.

😱

Now, doctor, a more important question is what would you think if a patient came in with severe chest pain and a widened mediastinum?

😱

Even a fourth-year medical student (like myself) has learned that much already. Or, as a self-proclaimed practicing physician, do you disagree with that?

😱

I don't think picking up a dissection aortic aneurysm has been impressed upon me as a huge diagnostic dilemma if you're paying attention. Or, do you disagree doctor?

😱

I'm still a little disappointed that some people took my first post on this thread in such an inflammatory way

😕 😕 😕

 

[ERMudPhud]

😱

😱

😱

😱

😱

😱

😕 😕 😕

Good point but way too much work. 😀

 

[Skip Intro]

I'm still a little disappointed that some people took my first post on this thread in such an inflammatory way

😕 😕 😕

Nice, well-played with the intent to obfuscate, snipped from multiple posts (some of which were in ressponse to some flames towards me), and completely out of context.

Just like this...

Sometimes our program inserts a metal rectal probe, and every time we get a question wrong they give about 300 joules to help wake us up. I kinda like it...

http://forums.studentdoctor.net/showthread.php?p=1769713#post1769713

😱

It's still all good, though. 😎

-Skip