We get called to a nursing home for abdominal pain and possible kidney or gallstones. We find an 88 year old man, alert and oriented, in no pain. The nurse explains he had an unresponsive episode earlier in the day. They did an ultrasound which revealed he had an Abdominal Aortic Aneurysm, multiple gallstones and a cyst on his kidney. Now almost ten hours later, the doctor has told them he should go to the ED to be evaluated. The nurse says she has just gotten off the phone with the emergency room. They are expecting him.
His blood pressure is 92/62. His SAT on room air is 99%. His respiratory rate is 18. His End Tidal CO2 is 35. His belly is soft and nontender. He said it was bothering him earlier in the day, but okay now. There are no pulsing masses. His distal pulses are all equal. The only abnormal finding is his pulse. It is 32. He is not on any beta blockers. I do a twelve lead. He is in 3rd Degree Heart Block. Looking through his paperwork, I see he is a DNR.
Since he is asymptomatic, we go to the hospital on a non-priority. We have a very nice conversation. His last name is the same as a man who used to play for the New York Giants. I ask if he is related to the football player. He says the man is his brother.
At the hospital, the triage nurse, who I believe is new, asks “Is this the AAA?
“Well, sort of,” I say. “There is more to the story. I try to explain everything that is going on, but she doesn’t appear to be listening. “When was he unresponsive? This morning! Why did they wait to call?”’ The hospital’s automatic cuff come sup then with a BP 50/30. “Look at his pressure,” she says.
“That’s not his pressure,” I say. “It’s much higher. It’s been very steady at 90/60. His problem is...”
“They’re waiting for him in room C,” she says impatiently.
“...he has a low pulse rate.” I say. But she isn’t listening.
We take him to room C where we are met by a doctor and two nurses. Before I can even tell the story, I hear the triage nurse say she is alerting the OR that the Triple A is here and needs to go right up. Then I tell the story. This is Mr.____, I say. He was unresponsive earlier, I say, they did an ultra sound that showed the AAA, gallstones and a cyst. He is now alert, no pain, mentating, good capillary refill, good pulse saturation. His pulse is 32. He is in a third degree heart block. Oh, and by the way, he is a DNR.
As I am giving the report, his BP on their machine comes up 90/60. The doctor, who has been listening to me the whole time, tells a nurse. “Call the OR back.” He shakes his head.
***
What is going on? Well for one, they probably didn’t know he was a DNR and that makes it less likely they would undertake a major surgery. But that aside, the question I am asking is while he may have a Triple A, is it dissecting right now or even close to bursting? A triple A is one thing a dissection Triple A is another – that’s the real emergency. My guess is the man simply needs a pacemaker. Why was he unresponsive earlier? From past experience dealing with nursing homes it could be anything from he was tired and sleeping to he had a small stroke or seizure, or he vagaled or had an arrhythmia. So because he said his stomach had been bothering him, they did an ultrasound and discovered all these problems that he may well have had for years that no one knew about. He’s 88 years old, for goodness sake. People hear AAA and think someone is dying. So his heart rate is 32. It may have been that for sometime and they only now noticed it. Sitting in bed, he may be able to get by on 32 because he doesn’t exert himself. The odds are he is probably an old athlete like his brother so he has a strong heart. Time has eroded his electrical pathways, but he’s still pumping well enough to perfuse his brain. A pacemaker will definitely perk him up, but I don’t think he needs to be rushed to the ED to have his belly cut open.
“Mr. _____,” the doctor says. “Any relation to ______, the old football player?” He smiles when the man says yes. “I saw him play at the old Yankee stadium back in the 60’s,” the doctor says, leaning forward against the bed railing. “Hell of a player, your brother.”
The two talk.
