Wednesday, February 16, 2011

"Aha!" Moment

I went for a run this afternoon with Prof. Goljan and listened to the part 1 of the cardiac lectures. 
He was talking about aortic aneurysms and aortic dissections and so of course my mind wandered off, recalling the most traumatic ambulance nurse escort I've ever done (outcome aside).

Dr. Goljan mentioned one of the salient features of aortic dissection: the midscapular back pain. This was the complaint which alerted me to the aortic dissection pathology in my 'mild chest pain' patient that day in the emergency department.

In passing Goljan said, "of course the pain is different than cardiac pain because the aorta is retro-peritoneal so it radiates into the back not down the arm".

OF COURSE!

In anatomy we have had to go through cardiac pain, and referred pain a million times, and the dermatomes, the arm, the jaw, blah, blah blah...and then other times we've talked about abdominal structures, retro-peritoneal verses intra-peritoneal, etc. etc. and the aorta being a retro-peritoneal structure.

But I never really thought about the connection with aortic dissection and the pain pattern!

(I know this has probably been dead obvious to all of you nursing/medical people reading this, but it just clicked in for me today).

AHA!

I have known for so long: mid-scapular back pain =  red flag = do bilat leg/arm BP's = ?dissection.

But it wasn't until today that I understood why that was the case.

Ok medical school, we've officially kissed and made up this week. I (heart) you again.

14 comments:

Cartoon Characters said...

I hadn't read that story before....wow. Very powerful. Great writer you are! Amazing...and good job! I am going to have to go back and read a few more blog posts of yours!

Absentbabinski said...

I knew none of the above, but now I do! It's always nice when something clicks into place, isnt't it?

And it's a damn sight more interesting than the sociology essay I'm doing at the mo...

Grumpy, M.D. said...

The fun part is you'll go to the gym next week, and while working out your arms you'll hurt something, and suddenly have pain between your shoulder blades and think...

Headstrong said...

Those kinds of "Aha" moments are marvelous! On a different note, I remember running with Goljan (Ed, I call him now, as we've spent so much time together..) blasting on my iPod, too - good times! Thanks for sharing!
Cheers,
Headstrong

MDToBe said...

That's so cool! I didn't know that either - but having read it here (in a reading environment that's funny and interesting and which I *like,* instead of in all my dry, verbose textbooks) I doubt I'll ever forget it. Thanks!

Albinoblackbear said...

CC--Thanks! I used to actually take the time to sit and write about the wild and crazy world of emergency departments and Arctic hideaways. That is why I feel sort of sheepish now with this 'tale of 10 textbooks' blog. =)

AB--It is, it almost makes the pay cut (to ZERO), debt, distance, and sleep deprivation worth it! hahah

Grump-Damn you! So very very correct.

HS--Indeed they are wonderful. Yeah, Ed and I are bonding on a continual basis these days. Would love to actually meet "Poppy" one day.

MD2B--No probs, glad someone else learned something today as well! =)

iamnothouse.com said...

See, I love those "aha" moments, but I find they rarely come with an anatomy-book learnin' connection, but rather with a disease and a patient (for example, I will never forget the signs and symptoms of rheumatoid arthritis thanks to the first lady I ever saw on the medicine wards back in first year).

Maybe it's different if you've done nursing before or some other profession where you've had fairly extensive patient contact.

Albinoblackbear said...

It definitely is different coming from a medical background because so much of what I am learning now gets hung on memories from the ED or Outpost work. Every single PBL case we've done this year brings at least one face to mind.

The COPD'er who discharged himself AMA after I dragged him out of his car in the parking lot and into the trauma bay, the diabetic with gas gangrene whose wife yelled at me when they amputated his foot, the malignant HTN who coded while I was triaging her, the RSV kid whose sats were 76% when I was snowed in in Pelly Bay...etc...

I used to kick myself for not doing something more specialized in nursing, giving me more in-depth knowledge in some area. But now I am really glad I did ED and public health because in 6 years I've seen you know, all the common things hundreds of times. And maybe one of some of the rarer things.

Albinoblackbear said...

Because, YES, clinical experience is where it is AT.

And definitely what drives everything home.

Hence why this part of the course is like a sharp object in my eye socket right now.

PGYx said...

Haven't listened in a long while, but I <3 Goljan. I suspect he will bring you many more Aha! moments. He has a way of tying together basics that every med student has learned to bring a fresh perspective. Helps a ton in real life and for the USMLE, too. :-)

His book is a great accompaniment to the audio if you ever listen while sitting down. Taking notes directly in his book helped me to better process, retain, & revisit the pearls he dispensed.

Threehills said...

Fun fact related to AAA I learned myself this week...

If one were to ascultate behind the knee, and heard a bruit, its 90% assoicated with AAA. AKA, a poor mans cat scan.

Albinoblackbear said...

PGYX--Oh definitely, I love his knack for doing that. I am going to start re-listening to some of the ones from runs in front of a text. I am a visual and auditory learner so I think I'll get more out of them that way as well.

TH--Innnnnteresting! I haven't heard that before (mind you, I fear I wouldn't pick up a bruit if it slapped me across the face). hahah

By the end of the ambulance journey (from HELL) my dissection patient had no pulse whatsoever in his left leg, to the point where I had to use the doppler to get a femoral pulse.

Elise said...

I know it's a month and a half after this post, but I had to leave this comment. I do medical transcription/speech recognition work, and tonight I just finished a report where a guy had the back pain you described here and the first thing I thought of was this. The guy presented to urgent care, they got a CT but sent him home, then someone read the CT over and brought him back in and they're doing a CT angio to make sure it hasn't ruptured. I did a silent cheer in my head that if an aortic rupture is what happened or is happening, that someone has caught it so it can be fixed.

Albinoblackbear said...

Elise--YIKES!! Hopefully it all turned out ok. Wouldn't want to be the doc that sent him home...