THE MORNING REPORT

The Best in FOAM Education

  • Ashley Mogul, MD

Big Win, Big Loss, Big Red: A Year in Review


In 2005, psychologists Fredrickson and Losada published on the critical positivity ratio with the idea that the ratio of positive to negative affect differentiates a person who flourishes from one who languishes1. Through complex mathematics they determined a critical ratio of 2.9: we therefore must have about three positive experiences or emotions to balance each one negative. Though the ratio itself has been challenged, it does seem true that our negative experiences hurt us more than the positive ones lift us up. I have personally found this to be very true when reflecting on the aortic catastrophes I have seen over this past year.

#1

I received a prehospital notification of a male in his 70s with history of aortic root aneurysm who called for chest pain. En route he began to have numbness of his lower extremity and became altered. Upon arrival to the ED, I noted that patient was unresponsive and pulseless and began CPR. We activated our Code Aorta due to concern for dissection leading to arrest. The patient was noted to be in PEA and bedside ultrasound revealed a pericardial effusion. Vascular surgery deemed the patient not a surgical candidate so after attempts at pericardiocentesis without significant change in patient’s cardiac activity, the patient expired.

This was an emotional resuscitation: this patient who was a fairly healthy and active man had been able to call for help himself just minutes before and I had to stand by waiting for him to arrive as I received prehospital notifications which convinced me that he was actively dissecting in the ambulance. I found myself wishing he had come even just minutes earlier- that there was more we could have done. This one negative case weighed on me for weeks as I pondered what we could have done differently with my mind continuously coming up blank. It is only with reflecting upon a few aortic disasters with great outcomes that I can find peace in this loss.

#2

I was walking down the hall of my zone in the ED when the nurse called me to evaluate a patient she was concerned may have just seized. The patient had yet to be seen and I learned that she was a female in her early 70s with history of nephrolithiasis and hypothyroidism who presented complaining of right lower quadrant pain. Her triage vitals had revealed a heart rate of 48 but otherwise she was afebrile in triage with a blood pressure of 139/76, alert and conversational. On my initial evaluation she was pale, diaphoretic, and intermittently responsive to my questions. Fingerstick was 127, repeat vitals essentially unchanged from triage. My attending requested we move the patient to our resuscitation room, at which point repeat vitals revealed a blood pressure of 52 over palp. As the team worked to start central and arterial lines, I began to ultrasound the patient. I was unable to visualize any recognizable structures in my FAST views of the right and left upper quadrants due to body habitus and what seemed like air or something obstructing, but when I placed the probe on the patient’s epigastrium, a 7.7 cm aorta with possible free fluid posteriorly revealed itself. CT which was performed in tandem with vascular surgery notification showed a 7.0 x 6.5 cm infrarenal AAA with rupture into the right sided retroperitoneum. The patient was taken emergently to the OR for endovascular aortic repair and is doing well to this day.

#3

I was in another patient’s room when I heard screaming in the hallway followed by an announcement “new patient critical care room 3” overhead. I walked into the room to see a young appearing 50 year old man with history of hypertension complaining of severe pain of his abdomen. He had been sitting on the toilet attempting to have a bowel movement when he had sudden onset of severe abdominal pain. EMS had astutely recognized decreased pulses of the right lower extremity. The patient was clearly uncomfortable, with a distended abdomen and diaphoresis. An upright chest xray was performed for possible free intraabdominal air and when negative, he was immediately taken to CT which revealed a Type B dissection just distal to the left subclavian, extending to the right common iliac artery and almost completely occluding the SMA. After controlling blood pressure with esmolol, nicardipine, and nitroprusside drips, he was taken emergently to the OR for thoracic endovascular aortic repair with stenting of the iliac and is doing well.

Fredrickson and Losada would tell me I need one more win to get my positivity ratio up, so here it is. This one a bit of a miracle in my opinion…

#4

A woman in her 70s presented to the ED with abdominal pain. As the nurse wheeled her by my desk and into a room I overheard she had recently been here for the same. On quick chart review it seemed that she had presented 5 days earlier and was found to have a 7.6 cm AAA with concern for rupture. This was an incidental finding on a right upper quadrant ultrasound performed for possible biliary colic due to her complaint of intermittent right flank pain, further evaluated subsequently by CT of the aorta. She had refused surgery due to concern for prolonged recovery phase and decided on comfort measures. On the morning of her second presentation, she stated that she was tired of having pain in her abdomen and was amenable to surgery. The patient was pale and we were unable to obtain a blood pressure. Code Aorta was activated, we obtained an arterial line with an initial blood pressure of 61/40 and simultaneously obtained a cordis through which we began transfusing blood. The patient went to the OR emergently and had successful endovascular aortic repair. How she survived for 5 days with her rupturing aorta I will never understand.

Take Aways:

  • If your patient is sweating, you should be sweating.

  • Let kidney stones and biliary colic be a diagnosis of exclusion.

  • Let’s flourish this year: for each loss we have at least three wins, it’s just a matter of reflecting on the good and not just on the bad.​

Ashley Mogul is a third year resident and the Academic Chief at Stony Brook.

@JustAMogul

References:

  1. Fredrickson BL, Losada MF. Positive affect and the complex dynamics of human flourishing. Am Psychol 2005. 60(7): 678-86. PMID: 16221001


Stony Brook
EMergency Medicine

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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