As I have progressed into my second year of family medicine practice, I have realized that certain patients have a tendency to stay with me. If you are in your clinical rotations or in practice, you probably can relate.
Perhaps it is the face of the child who was the first otitis media you ever diagnosed. Maybe it’s an older patient who taught you a life lesson. Maybe it is the first life you saved.
This particular patient encounter remains vivid and meaningful for me because it was the first time in my career where I was forced to dig deeper than I knew possible.
It was my fourth rotation in PA school. I was rotating in a small emergency department in a town that had more cows than people. I can still see the face of the attending as he said, “We’ve got a level 1, critical. Chest pain, altered mental status. If you get in trouble, come get me”.
I was all but sure he could hear my heart enter an abnormal rhythm. “Remember your training, you can do this”.
As I have grown into my role as a clinician, I have realized that every health care provider has a defining moment. The sink or swim moment where your limits are tested and you must rise to the occasion. This case was mine.
Entering the room, I saw nurses everywhere. EKG strips. IV lines. Paramedics. The crash cart. As adrenaline took over and the fear abated, I realized that my patient was in trouble. In fact, he was crashing.
He was a 40 year old male with no past medical history who was found with a decreased level of arousal by a friend. His only complaint en route to the emergency department was “chest pain radiating to my legs”. Nurses began yelling out vital signs to me. “Pulse 110 and thready. BP 110/66, respirations 24 and increasing”.
My only thought was whether my pulse was higher than my patient’s.
As I began my brief history and physical exam, I knew something was wrong. The patient continued to repeat himself after each question I posed. Each response was accompanied by a grunt, groan, or oddly a very boisterous hiccup.
The majority of the history was focused on his chest pain, but my patient continued to offer very little supporting information. A brief exam revealed no obvious focal abnormality. No signs of a stroke. No murmurs. No adventitious lung sounds. No obvious source of trauma. Bowel sounds present but hyperactive. His vitals continued to plummet. His hiccups continued to increase in frequency.
When my preceptor arrived in the room, any formal presentation of this patient was lost. I took a deep breath and began. I gave a 30 second summary of the history and my exam. Then the looming question: “What would you like to do?”
The moment arrived. I could feel myself drowning. After taking a deep breath, a moment of clarity came over me. “Airway is stable. 1 liter normal saline bolus. Aspirin. Morphine. CBC. CMP. Troponin. Sepsis Panel. Chest x-ray. CT head, chest, and abdomen. Crash cart ready”.
After that, things moved fairly swiftly. The patient was stabilized. The hair on my neck continued to stand, however.
The differential remained extremely broad. After stabilizing the patient, my preceptor and I discussed what could kill our patient in the next hour. The conversation ranged from myocardial infarction to stroke, pulmonary embolus, sepsis, perforated peptic ulcer and everything in between.
We had very little information from this patient. As we waited for labs and imaging to come back on our patient, I could not help but consider the patient’s continued hiccups. In all of the chaos, this symptom remained stable.
The CT scan came back about 20 minutes later. Our patient remained stable, but we remained guarded. When the radiologist read his report to us over the phone, we were stunned. “Full thickness tear of the thoracic esophagus with extravasation of gastric contents and a resultant chemical mediastinitis”.
A real life zebra. But a deadly one.
The patient was stabilized, made NPO, and started on broad spectrum IV antibiotics. A surgical consult was placed and the recommendation was made for transfer to a distant tertiary care center. The patient survived, but barely. No inciting event was identified.
Initial gut feeling plays a tremendous role in medicine. This is something that we continue to develop as we progress in our careers. We strive to always improve our clinical knowledge and our decision making skills, but sometimes our gut instinct trumps everything.
In this case, quite clearly this patient was sick. His presentation, however, was atypical, erratic, and confusing.
During the case, I remained overwhelmed by the feeling that something was terribly wrong. No textbook finding. Nothing the patient could tell me. Nothing the EKG could tell me. Something just was not right. Every bone in my body seemed to agree. This overwhelming sense of doom ultimately motivated me to pursue a more aggressive workup in this patient.
A career in medicine is a guarantee of continuous challenges. Infections that need treated. Patients that need counseled. Bones that need fixed. Sometimes the most trying situations teach us the most not only about medicine, but about ourselves in the process.
Your comfort level will continue to be tested. Your gut will continue to help guide you through your process. Listen to it, but don’t be afraid to go out of your comfort zone. It’s the way you grow as a clinician and a person.
Boerrhave’s syndrome is defined as a full thickness rupture of the esophagus. It is extremely rare, but is universally fatal if not identified and treated appropriately. Causes of this deadly syndrome include extreme retching from vomiting, seizures, prolonged laughing, weight lifting, and iatrogenic.
Depending on the area of rupture, patients may present on a large spectrum. Patients may present stable with complaints of chest pain, dysphagia, neck pain, or even back pain. Chest pain is usually described as retrosternal and can be excruciating.
Hiccups are not common.
Patients presenting early in the course may offer few complaints. Patients presenting later in the course may be in respiratory distress with tachycardia, fever, and hypotension.
Physical exam may be non-specific due to the broad differential diagnosis in these patients. Patients may have tenderness or crepitus of the chest wall. The classic “Hamman’s Crunch”, or an audible crunching sound in sync with the patient’s heart beat, is rarely observed.
Initial work up includes labs, chest radiograph, blood cultures, and potentially a CT scan. Chest radiograph findings can include pleural effusions, a widened mediastinum, or may be normal. A contrast esophagram can show extravasation of barium into the mediastinum. A CT scan may show the presence of gastric contents in the mediastinum.
The diagnosis is usually an incidental finding in the workup of pulmonary embolus or myocardial infarction.
Management of these patients is typically surgical. Initial recommendations include ICU transfer or tertiary care transfer, NPO status, broad spectrum antibiotics, and proton pump inhibitor therapy.
Stable patients with minimal symptoms and stable vital signs can undergo a trial of medical management, but many of these patients require surgical involvement.
Unrecognized Boerrhave’s syndrome is entirely fatal.
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