The Patient Was…

The patient was a 65-year-old man who lived in the capital city of a country in the southern hemisphere.

He usually saw me for a routine checkup once a year around Christmas time, when he came to New York for business meetings. His business partner, who lived in New York and was under my care, had originally referred him to me.

The patient was in generally good health except for mildly elevated blood pressure and cholesterol levels which he refused to address by either medication or life-style changes. His general doctor, back in his native country, never suggested that he try to lower his blood pressure or cholesterol, so the patient didn’t regard it as important. On examining him yearly I never found any evidence of vascular disease, which would have been the primary expected consequence if the increased levels of blood pressure and cholesterol were doing any damage.

His business partner always made the appointment for the patient to see me for his annual checkup, so I normally never heard from him except when he arrived at my office for his examination. So, I was surprised to one day receive a telephone call from him in his native country.

His medical story was one I had never heard before. He was lying on the beach shortly before calling me, relaxing following eating a sandwich. After a while, he changed position, rolling from his back onto his stomach. As soon as he did that, he began to feel his body moving slightly up and down in a rhythmic manner. His first thought was that the ground could be moving and it might be a small earthquake. But looking around, nobody else on the beach seemed to be aware of anything unusual or alarmed in any way.

He turned over onto his back and the feeling went away. So, he thought nothing of what he had just experienced. After a few minutes, he rolled back onto his stomach, and the feeling of rising and falling returned. This time, he recognized that something was not right, but he was completely baffled by the symptom.

He rose and called his regular primary care practitioner who listened to the story and pretty much dismissed it as some sort of stomach or intestinal response to the sandwich he had eaten. Fortunately, the patient wasn’t convinced. This was not like any stomach or intestinal symptom he had ever heard of or felt. It was just weird enough to worry him sufficiently to seek another opinion. And I was the only other doctor he saw with some regularity.

As I listened carefully to his detailed description of what he felt  —   his body rising and falling rhythmically as he lay on his stomach  —   I could think of only one alarming explanation: a large abdominal aortic aneurysm.

A aneurysm is a bulging or ballooning of a blood vessel due to a weakening of the vessel wall. Occasionally, weakness of the wall of the heart itself can cause an aneurysmal bulging of one of its chambers. An aortic aneurysm, which is what I suspected in the patient, is a bulging of the wall of the aorta, the largest artery in the body.

As blood is pumped from the heart into the aorta, the force of the blood pushes against the blood vessel wall. If there is weakening of the wall, the aorta can bulge like a balloon. When the heart rests before the next beat, the bulge slightly retracts. Since a large aortic aneurysm can exert pressure on the wall of the abdomen, the alternating expansion and retraction of the bulge could conceivably lift the body slightly and then let it down enough to be felt, in sync with the heartbeat.

Since large aortic aneurysms can rupture without warning, causing massive internal bleeding, they are a serious medical problem. I explained to the patient that while I could not prove that what he was feeling was due to an aneurysm, I couldn’t think of any other reasonable explanation. If I were correct, he needed to seek medical care quickly. If I were wrong, well, I would be guilty of inconveniencing him by insisting he go the hospital immediately.

He said he did not trust the local medical people and he would get the next flight to New York. This was a really bad decision, in my view. Admittedly, there are no good data on the risks of aneurysm rupture associated with air travel. But the hassles and stresses in flying might raise his already slightly high blood pressure. The changes in air pressure in the airplane cabin could possibly increase the risk. And in the best case, it would be many hours until he could reach New York.

He was insistent on coming to New York for treatment, saying he understood and accepted the risks, and I could not dissuade him from his decision. When he had made travel arrangements, he sent me the details. I arranged for an ambulance to meet the flight and transport him directly to the hospital. One of my colleagues, an expert in vascular surgery, was on standby.

The patient was evaluated by the surgeon as soon as he arrived at the hospital and was immediately taken to the operating room. He had what was described as a massive aortic aneurysm, with leakage of blood into its wall; the surgeon estimated it would have ruptured within the next couple of hours. The repair of the aneurysm was successful, and recovery was complete.

The whole experience was highly unique in several respects. The specter of catastrophe loomed over every aspect of the case. Making a diagnosis of a potentially and imminently life-threatening condition on the basis of a telephone description of a weird symptom was unusual enough. The patient refusing advice to seek immediate local care was harrowing. The possible drastic consequences of his flight were frightening to contemplate. And the availability of immediate and expert care was beyond fortunate.

So many things could have gone wrong. So many decisions had to be made. And any of them could have had different consequences. Sometimes the stars align; be grateful for that. But do not depend on it always being so.