ER thoughts: John Ritter, lawsuits, and the aortic dissection

I just completed another shift in the emergency room (which I do about once per month), and it continually amazes me the amount of non-emergent cases that comes through – but that’s for another rant.

So I’m reading that the family of John Ritter is suing the hospital for misdiagnosing his ascending aortic aneurysm. Galen certainly has some tough words for this. I’ll reserve opinion since I’m not familiar with the case.

We’re taught there are generally four causes of chest pain that can result in sudden death. They are myocardial infarction, pulmonary embolus, aortic dissection, or tension pneumothorax. According to the story:

He was initially misdiagnosed with an acute myocardial infarction, then with pericardial tamponade, the suit states.

Generally, an aortic dissection needs to be suspected in order to be diagnosed – Medpundit has written about this today. 96 percent of dissections can be identified based on some combination of these symptoms:

1) Immediate onset of aortic pain with a tearing and/or ripping character,

2) Mediastinal and/or aortic widening on chest radiograph,

3) A variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure (>20 mmHg difference between the right and left arm).

Working in the ER, the first priority would be to ensure the cause is not one of the four “sudden death” causes. If the pattern didn’t fit an MI, a chest X-ray (routinely performed) would rule out a pneumothorax. That leaves dissection and pulmonary embolism as causes next to rule out. Chest CT would be the key test that would have caught the dissection (98 percent sensitivity). If PE was suspected, a CT angiogram would have been ordered.

Since the hospital’s working diagnosis was acute MI, and then pericardial tamponade (likely diagnosed via echocardiogram), I suspect that the chest CT wasn’t performed quickly enough, since dissection wasn’t high enough on their differential diagnosis (again, I’m just speculating).

I can only sympathize with the emergency room that night. With an acute aortic dissection, seconds count, and it was an unfortunate event for all concerned. Was it malpractice? Tough to say. The question I’d be interested in would be how long it took for the ER to order that chest CT scan.

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  • Rob Rogers, M.D.

    What amazes me is the fact that we as emergency physicians get sued for missing disease entities that simply cannot be made at initial presentation. Acute aortic dissection can be extremely difficult to detect, and guess what, it is lethal-sometimes no matter what we do. But, with the lotto mentality of the US, it really doesn’t matter what we miss-if there is a bad outcome it will result in a suit. Could John Ritter’s case of dissection have been picked up earlier? It is possible. Would it have made a diference? Unknown. It is a good reminder, however, to avoid tunnel-vision in our workup of chest pain patients and to consider ALL deadly diseases and rule them out appropriately. As I teach our emergency medicine residents, picking up the diagnosis of acute aortic dissection may very well rely on how frequently you consider the diagnosis.

    Rob Rogers, M.D.
    Assistant Professor
    Emergency Medicine & Internal Medicine
    The University of Maryland School of Medicine

  • Anonymous

    Re: aortic dissectiion
    While I understand the difficulty with such a diagnosis as aortic dissection, would not factors such as the patient is carrying a card informing the ER that she has a dilated aorta and aortic insufficiency, as well as a mother who died of an aoritc rupture, be significant?
    My sister died of aortic dissection 12 hours after arriving at the ER with severe abdominal pain, back pain radiating into the legs, vomiting and nausea. The ER never ordered a CT scan. They did an EKG, gave her an enema. Her pain subsided, then increased again. She arrived at the ER 6:30 in the morning, died at 6:30 PM never having had a chest x-ray, or a scan or seeing a cardiologist. I don’t understand this.
    I understand that there is no guarantee that my sister would have survived surgery but had she been scanned early, I believe she did have a decent chance at survival. We have been told by some attorneys that the “standard of practice” has been followed As a person who also has a dilated aorta, who now has a history of mother and sister dying from aortic dissection/rupture, what chance do I have if that was the standard of care?

  • Anonymous

    On Decembwer 21, 2004, my brother entered the ED at 10:30am. He had sudden onset on severe chest pain.
    The EKG was normal as was the chest Xray, (not yet
    read by radiology, so we don’t really no what it showed.
    He continued to complain of chest pain and despite a
    normal ekg they started a nitro drip and morphine. Neither worked for the pain and it kept getting worse.
    My brother arrested at 12:32pm, 2 hours after entering the ER. The Post showed ruptured aortic dissection and
    cardiac tamponade. None of these was suspected. In fact
    the ED doc told me my brother had some seizure activity?
    Seizure activity I asked. He said yes his eyes rolled back in his head and he fell backwards. That’s not
    seizure activity. Thats a cardiac arrest. That is when
    my brother arrested. The monitor still showed a rythm
    but no pulse. They worked on him for 20 minutes then called the code. They never suspected dissection and
    they should have. It may have saved my brother. He was
    only 49 years old, in execellent health, never smoked,
    never drank alcohol, exercised and ate right. He was even a former Mr. Michigan in body in the 1980′s.
    Something has got to be done to educate these ED docs.
    Maybe add it in the algorythms of ACLS. Maybe then it
    will stick in there heads.

  • Anonymous

    On Decembwer 21, 2004, my brother entered the ED at 10:30am. He had sudden onset on severe chest pain.
    The EKG was normal as was the chest Xray, (not yet
    read by radiology, so we don’t really no what it showed.
    He continued to complain of chest pain and despite a
    normal ekg they started a nitro drip and morphine. Neither worked for the pain and it kept getting worse.
    My brother arrested at 12:32pm, 2 hours after entering the ER. The Post showed ruptured aortic dissection and
    cardiac tamponade. None of these was suspected. In fact
    the ED doc told me my brother had some seizure activity?
    Seizure activity I asked. He said yes his eyes rolled back in his head and he fell backwards. That’s not
    seizure activity. Thats a cardiac arrest. That is when
    my brother arrested. The monitor still showed a rythm
    but no pulse. They worked on him for 20 minutes then called the code. They never suspected dissection and
    they should have. It may have saved my brother. He was
    only 49 years old, in execellent health, never smoked,
    never drank alcohol, exercised and ate right. He was even a former Mr. Michigan in body in the 1980′s.
    Something has got to be done to educate these ED docs.
    Maybe add it in the algorythms of ACLS. Maybe then it
    will stick in there heads.

  • Anonymous

    12 hours…try a week. My grandfather had his tearing…he had FULL cardiac arrest in a church during a Priest Anniv. ceremony! Tons of Doctors in there as you would expect. They actually revived him prior to the ambulance arriving & told the ambulance people it was Full arrest. The ER doc. did not believe it! They came in & brought letters signed it was full! They had him laying in Intensive Care for a week, ordering tests & then canceling them. He was filling up with fluid, looking grey & they said it was just because he was laying around…RIGHT! I always do when I get the flu or a cold! They release him FROM intensive care! My mom says, Hell NO , & takes him by ambulance to his regular hospital/doctor. One test & they find out what was wrong. He made the surgery, they actually repaired it but they had to scrap off tons of blood clots off the outside of his heart from it leaking for a week. His heart could not take that! It is just ridiculous! My parents should have sued & if it was me I would have! They were just grieving too much to do so! It would not have brought him back I know but we all know that money is really what talks & when you have a week & you cancel tests that is just crazy!

  • Anonymous

    I have an abdominal aortic aneurism, 7cms. Today is Tueasday, and I am going into surgery on Monday. The surgery is being done at Columbia Presb. in NY. I am walking around very scared, sought of like a ticking time bomb. Whenever I get a painm in my chest, I get scared and say this is it. Just wanted to share this with you.
    Ron
    ronran@optonline.net

  • Brad Boyd

    Reagrding the Ritter family lawsuit, I can say that I too survived an initial misdiagnosis of a dissected ascending aortic anerysm. The ER doc (who ironically is now my primary cardiologist) decided that I had acid reflux. Thankfully a second ER physician remembered John Ritter’s case and requested a CT scan. Instantly it was apparent what was wrong, but I spent four hours in ER and was dressing to go home when they changed their minds. I would have gone home and died in front of my wife and five year old son. I didn’t consider suing, nor do I think that our society is correct in suing at the drop of a hat, but in John Ritter’s case, the symptoms should have been self evident in my opinion. Why after all these months of hearing similar horror stories do ER docs ignore the big warning signs? Ripping chest pain, dizziness, acute abdominal pain that presents into the back as well? A CT scan, while expensive, is a no-brainer that would allow instant diagnosis. Early diagnosis admittedly will not save every life, but how many thousands die each year that could still be around to raise families, enjoy life and educate others? Those are my joys right now, and I nearly lost them due to, likely, an overworked ER doc who saw what he expected to see.

  • Anonymous

    I understand griel and anger.
    But I disagree that “all ER docs are this or that and you have to stick that in their heads”.
    Diagnoses are always cristal clear … AFTER. What is overlooked is that you cannot and must not do a CAT scan for every patient with chest pain in the ED.
    Docs will make mistakes , some humans working as doxtors may be sloppy. This is not the generalcase. making those diagnoses is really notr as easy as is written here, often the full blown clinical picture is not present at presentation.
    Now I’m not saying all docs are pefect.

  • Rob

    On 12-04-04 I was admitted to the ER for severe chest pain. No classic symtoms of a heart attack. TWO hours later after my wife (PA-C) mentioned to the ER doc that my father had a Type A dissection, they did a CT and found my dissection (Type B Class III) I hope I never experience such a medical nightmare from hospital staff ever again! They probably could’nt find their ass using both hands!!! I pray the Ritter family WINS their suit!!!!!!!!!!!!

  • Anonymous

    All I am hearing are very sad and bitter people. The expectation in this country is rediculous. Doctors aren’t supermen and people who don’t actually work in a emergency don’t actually know what’s going on. There are many things to consider when deciding who gets a CAT scan and who doesn’t. In my ER about 20-30% of the patients complain of chest pain. That’s about $100,000 for 30 CAT scans not to mention the risk of dye allergy and kidney damage. About 50% of the patients are uninsured so thats a $5000.00 ER bill the patient will have to pay or get there credit ruined. If your grandfather went into cardiac arrest because of an aortic dissection well then it was his time. Cariac arrest patients never walk out of the hospital. You don’t CAT scan dead people. Sorry, you don’t live forever! There is so much medical waste the last few months of peoples lives it’s absurd. (A different topic)
    If your brother was young, healthy, didnt’have any medical problems didn’t smoke and had a dissection well he must have bad luck. He doesn’t have any risk factors for aortic dissections. Did the doctor consider it? I don’t know. Do I consider it? On every patient, but I also consider the type of presentation, risk factors, etc. It’s not supposed to be that common, but in our ever expanding overweight out of shape society maybe young healthy and no risk factors should be risk factor. Since I finished ER training 7 years ago the amount of crap that has clouded working in the emergency room has just continued to grow. You have patients who don’t respect you and are willing to sue for anything regardless of whether anything was done wrong, hospital administration that want you to transer or dischage (even if sick) every uninsured patient, ER administration that keeps track of how many patients you see, how much you bill, how nice you are etc. ER doctors are like everyone else just trying to do the best job they can with about 100 times the pressure.

    LA ER DOC

  • Anonymous

    I am an ER doctor and I am horriefied by you fucks who think it is “self evident” or “obvious”. You don’t tknow what the fuck you are talking about. I happened to catch rwo in one night and I can tell you it is fucking hard to diagnose one every four years OK. Sometimes EVERYTHING can be normal and you will only catch it if you order a CT scan. Sometimes ordering a CT scan is contraindicatied because of allergies or renal failure. But “educating” ER doctors is not going to solve the problem. That really pisses me off. First of all – Mr. Ritter presented with an ST elevation MI and a normal CXR. IF you don’t tknow what the fuck that is shut up. He got thrombolytics and decompensated and thats why it got diagnosed. So it is VERY hard to catch this disease. There is no cookbook “1-2-3″ in medicine. So I am sorry this bad disease happened – but the survival rate is dismal and the ER doctor did not GIVE them the disease OK. Bad things and tragedies happen to all of us so blame GOD or whoever you think gave you the bad genetics. But to think magically you would walk out and healthy and rescuing kittens and feeding the homeless – fuck off. I feel bad when things get missed but literally it is a disease that is a needle in a haystack with the hay screaming “me first” yadda yadda yadda – “I want to go home”…”when are my tests results back”…”why are things taking so long”…

    You are fucking lucky you live in America where almost every ED has a Helical CT. You know what happens in EVERY other country – especialy with socialised medicine like CANADA (witch has better outcomes than the USA across the board)…people just keel over and die. You assholes who watch too mutch TV and think that just because you walk into an ER means you are going to walk out healthy, youthful, and playful – you are living in an illusion. There is a miss rate for everything! Blame the docs…give me a break!!!!

    LA ER DOC – 2.

  • Anonymous

    My mom went to the ER with chest pain, dizziness, and extremely low blood pressure on November 6, 2005. A CT scan was performed and analyzed and she was admitted into the hospital in the cardiac ward. She was sent home 3 days later with diagnosis of pneumonia. She had a follow up EKG done on November 17 but had no recollection of it the following day. She was taken back to the ER on November 18 and passed away on November 20. We ordered an autopsy and the result was that she died from an aortic dissection. In our meeting with 2 cardiologists and her primarty care physicians that were in her care for these 2 weeks they expained the autopsy and explained what an aortic dissection is. They also apologized that the cardiologist and radiologist had overlooked the CT scan and that it did show the tear in her aorta which was the cause of her being brought to the ER in the 1st place. How am I supposed to feel when doctors can’t even read the fucking scan that could have saved her life!!!

  • Anonymous

    Please don’t try to generalize all doctors together. What do you do for a living? Do lives hang in the balance? Maybe all docs should go on strike due to all the lawsuits and then we’d see what you screwballs have to say. Sure there is malpractice that happens, but every single situation is unique, and as stated above, there is NO COOKBOOK for medicine. For those who have lost family members, I am truly sorry, but you still don’t have the right to lump all docs into one pile.

  • Anonymous

    LA DOC-2
    Love your work- could not have said it better myself!!
    Australian GP

  • Anonymous

    Wow, I wonder if it is any coincidence that the more profane and self-righteous posts are all from “doctors” in LA. Nice language “doctor”. I agree that everyone dies sometime, and no doctor or hospital can find or cure everything. But those of you who only see the dollar signs are a symptom of an over worked system that produces jaded assholes like yourselves. I am thankful I had the good fortune to live not just in the Midwest, but as far from the land of Plastic People and Plastic Surgery as I do. I don’t delude myself into thinking that every test should be run on every patient that comes in with a stomach virus, but not even taking the symptoms into account and telling someone they have acid reflux and telling them they can leave is a nuisance until it happens to you, then it is more than just a pain in the ass, it is your life. And you are correct, a lot of us do not understand your medical jargon, but evidently, neither do a lot of you Doctors.

  • Endo

    I am an ER doc in the Midwest. It’s hard to pass judgement on cases without all the data. Aortic dissections are rare and often don’t present like the textbooks say they should. I’ve seen a total of 3 — one of which I missed. This one presented with vague abdominal pain and a normal chest xray (abdominal series). I don’t think the lay public understands the pressure ED docs are under every hour they work and how little “thinking” time we have to devote to each patient. We see a ton of chest pain and are actually very well educated on life threatening causes of chest pain (including dissection). The fact that we miss dissections is related to the rarity of this disease, the number of atypical presentations and the fact that we are human. It’s easy to look back at a case and say “well obviously this is a dissection”. It’s not so easy when you’re seeing 12 patients at a time and run into a poor historian who has an atypical presentation. Problem is, Americans don’t accept that bad outcomes occur — and if an ER doc makes a mistake we assume that he has committed malpractice and should pay. We like to blame when bad things happen. Our culture doesn’t accept death. But ER docs, no matter how smart or educated are going to make mistakes because they are human, they are under a great deal of stress, the are under severe time constraints and medicine is not nearly as easy as some people think.

  • Anonymous

    Dr. Rogers, Can you imagine being sent from one hospital to another hospital with paper work in hand informing the second hospital, but not the patient or their love one, that an aortic dissection condition had been confirmed. Upon arrival at the hospital the patient is escorted to a room with no doctor or nurses in sight and just told to wait until teams of doctors arrive to perform some kind of surgery. Unfortunately these teams never arrive and the patient who thinks everything is just fine dies a few hours after he arrives. So I ask you what good does it really do if we are fortunate to find an expert in his field capable of avoiding tunnel-vision and appropriately diagnosing this disease if our hospitals are not staffed properly to handle the emergency when it accrues?

  • don

    On 2-11-01 I had an etremely complex aortic dissection. It took in excess of 48 hours to diagnose it and surgical repair could not be done for 12 additional hours. Yet here I stand. Medical malpractise and incompetency are very serious aqusations.

    In my case I went to my local regional medical center that does not have an ope heart program and isn’t even close to having a trauma center approach. I went there because I knew that something deathly was wrong and that they could keep me alive and get me to the place or person that could save my life. The way I felt that night I would have gladly gone to a vetenarian if that was all that was available!

    Seriously, in my case the ER physician was the only MD in the hospita at that time of night and his help was one 1st year med student learning to take HnP’s and a first year resident. My case was being approached as an epigastrict tear due to the pain description, the ipslateral BP’s and High BP was accepted as an adjunt to other morhology. CT scan/Barium swallow was done within a few hours of admit and ruled out an E-G tear, however…this was a wet read by the ER MD and his students because no radiology MD’s on duty for the overnight. Next day now new admitting doc wants his own CT scan, and hasn’t bothered to read the Rad report or maybe it hasn’t reached the chart yet. Luckily the CHief of radiology was there when they wheeled me in for second CT scan, and he stopped this parade and demanden that I be transfered out for emergency surgey.

    5surgical centers turned down the case. The surgeon that accepted the case neede 12 hours before he could do my repair due to his performing a AAA at the time of this hospitals call.

    Well I was heavily sedated, and BP lowered to almost nothing for twleve hours and then packed up and sent to this other Heart Transplant Center where a successful ascending graph and A-valve repair was done.

    My feelings…This disease as much as we want it to be a no brainer to diagnose, is not. It is now being diagnosed more often and the appearence in the general population is increasing. This is only due to advances in imaging technology. Succesfulr repair statistics have not changed much in 5 years its still has a morbidity of 2% per hour will die from onset no matter what is or is not done. Surival from leaving the OR is not much better. Less than 10% survive the surgery better than a parapalegic or brain dead. So unfortunatel for the Ritter family, His chances of survivng even if every thing went in his favor are slim to none. Finally you must also examine the patients that have been fortunate to survive a dissection repair, most are under 6 feet tall younger than 45 and none are overweight ( greater than 180-190 lbs.) Per the above Ritter unfortunately was not going to survive an emergent surgical repair for an A-dissection.

    The question of the doctors being incompetent and there being malpractise. Probably not.

    In my case was there malpractise maybe/maybe not the key question for a jury would have been beyond a reasonable doubt had he been harmed or damaged by anything the doctor did or did not do, no, because I’m Still alive! case closed.

    For the Ritter family ask the same question, and his outcomre no matter what was sure death.

  • Anonymous

    Obviously, there are two sides to every story — but I am outraged and offended by the LA doctor who finds it necessary to curse out all of us who have lost people due to ER misdiagnoses regarding aneurysms — and YES, that’s what they are –misdiagnoses. My healthy, 64 year old father was sent home from an ER on 10/31/06, still complaining of the chest pains he walked in with, and 10 hours later, had a thoracic dissecting aneurysm, “coded,” and was brain dead. So to all of you doctors who think that you are “only human,” yes, that is true, that goes for all of us. But we don’t put our trust in the mailman or the garbage man — we put our trust in YOU — YOU, who are supposed to know these types of things. We’re “lay people;” we don’t know any better. That’s why you have the medical degree, and I don’t. But I do know when a man is in excruciating pain — you don’t have to go to 10 years of med school to see that. Furthermore, who gives a damn about the cost of a CT scan or a credit score if it would have kept my dad alive? That is a ridiculous argument, and if you really believe that, why the hell are you a doctor? Hopefully, your loved ones will never experience the shoddy medical care that my family has been exposed to, and don’t be so defensive — it makes your case look weak. Hope you sleep well at night.

  • Margaret

    Five years ago, at the age of 48, I suffered an acute aortic dissection. I was taken to the closest emergency room where I spent the next 3 to 4 hours while the ER doc commenced with exactly the protocol referred to in one of the previous emails EKG, chest x-ray, CT scan. Let me tell you, the gods were lined up in my favor!
    First, I live in a city with some of the finest medical care and THE finest trauma care in the nation – Seattle.
    Second, my dissection occurred on a Tuesday evening – just one old drunk in the ER.
    Third, it was a first rate neighborhood hospital that was connected with the finest hospital in the city. (By the way, the neighborhood hospital is going away.)
    Fourth, a super-conscientious ER doc. I happen to have acid reflux and it would have been easy to connect my symptoms with that. My blood pressure, heart were all fine, although my father died at 50 from a heart attack.
    Fifth, the ER doc knew just who to call so that my emergency surgery could get underway, pronto. (I never had any kind of surgery before in my life, and now I was facing open heart surgery!)
    Sixth, after I was taken to the “big” hospital, where I had the best heart surgeon in the northwest to perform the 10 hours of surgery. (The surgery had only been available in Seattle for two years prior to mine.)
    Seven, I spent a month in a medically induced coma due to my extreme reaction to the intubation – my blood pressure would skyrocket and I would struggle with the hospital staff when they attempted to wake me and remove the tube. While in the coma I nearly bit it several times due to a variety of complications – serious infection; near kidney failure; etc. Through it all, I had family near me and advocating for me nearly 24 hours a day. My mother moved from another city and stayed in my home, and my former mother-in-law even came to visit! Every bit of energy my mother, siblings, nieces and nephews, aunt and uncle – you name it – could muster was directed at my surviving.
    Finally, I had phenomenal health benefits! Of everything, this is probably the single most significiant factor in my survival. There was no hesitancy to order a CT scan. There was no reluctance to send me to the finest hospital in Seattle. Great surgeon? – no problem. Month in a coma? – what else can we do for you? Three months in recovery in the hospital? – wanna make it four? How about when you leave the hospital? Hospital bed, PT, home nursing care, equipment, you name it. (Even the cotton balls.) It was all taken care of…no muss and NO FUSS! The entire business cost between half and three quarters of a million $. My out of pocket was less than, get ready for this…$1,000. This does not include my short and long-term benefits so that I could recover w/out worrying about bills. Am I wealthy! Let’s put it this way, I work in social services and I am a divorced, single female. What do you think? All I can say is that my experience should not be the exception. This is what we all deserve. I know I was very, very lucky and don’t think for one moment that I don’t know it. I am grateful for every breath I take and for every event I would have missed if I hadn’t made it (exception for current White House administration).
    Nobody in this wealthy and brilliant nation should have to expect or receive substandard medical care. Unfortunately, the only means of addressing the issue is through the courts. When are we going to wise up and stop throwing people away when we know what needs to be done. We absolutely must have universal health care, and we double-absolutely deserve the best care there is to be had!

  • Anonymous

    I’m a Registered Nurse. I understand the pressures ED Doctor’s have and I don’t believe in suing.
    However, my husband had a dissected aorta a year and a half ago. He went into the ER by squad. He call the sqaud at 4:15 pm. EMS told the ED Doctor that he was having an anxiety attack. My husband told them he was having chest pain and that is what led him to calling EMS. He arrived at the ED at 4:45. He told the doctor his leg was in severe pain and burning. The doctor told him if he would just be quiet he would get him something for pain. When I got to the ED at 5:15pm he had a brief full of blood, the second one my husband told me. He was also vomiting blood. Still not seen by a doctor. I told the nurse at 5:30pm he had no pedal pulse and his foot was gray. Still not seen by a doctor. Approximately three and a half hours later the doctor came in, no pulse to his right leg. He called a surgeon. They finally did a CT scan. Shipped him to a bigger cardiology hospital. Did not know if he would make it.
    He did make it. He is permanently disabled has no function of his right lower leg, constant pain, walks with a brace and cane. Permanently no function of his leg from the knee down. Could this have been prevented if they would have listened to the nurse wife and my husband yes. I asked questions I told them his pressure was erratic. I started low d/t him bleeding out I told the nurse he had no pulse. I think the doctor should have listened to my husband and myself.
    Yes it is hard to ditect a dissection but if the doctor would have listened my husband may not be paralyzed from the knee down. Yes he is alive but there are days he wish he weren’t because of the severe constant pain.
    Was John Ritter’s wife right to sue. YES, YES, YES!!!!!
    Doctor’s need to look at a dissection immediatley with anyone who states chest pain but the EKG is normal and immediately order a CT scan.
    By the way my husband had no idea he had any problems with his aorta. He worked all day everyday as a mechanic. He is now 50 this happened when he was 48.

  • Anonymous

    your comments that every patient with a normal ECG with chest pain reflects a common misperception about the evaluation of chest pain in the emrgency department. Th fact is, and as unfortunate as your husband’s case was, thoracic dissections are rare. If you performed a Cat scan of the chest on every patient presenting to the ED with chest pain and a normal ECG you would actually kill more people than you would save. For every 3000 cat-scans of the chest a doctor orders one cancer is created in terms of radiation dosage. Given the millions of ED visits for chest pain, you would likely cause more malignancies that detect dissections. This is by no means to detract from your husband and your loss, it just is not a plausible strategy…thoracic/aortic dissections remain elusive and frequently are missed, but a shotgun approach to scan every patient with chest pain would likely create more problems than less, (not even counting the kidney failure from dye, allergies to dye etc…). If it were this easy we would scan every patient with chest pain and that would be the end of it. Emergency doctors don’t get more money by saving the hospital money by not scanning people.

  • mortaldoc

    “Walk a mile in my shoes, please…”
    Friends, when you bash physicians consider these obvious truths…
    I have never in my life met a person who never made a mistake.
    I have never met a person who got a 100% score on every test he or she ever took from kindergarten through the end of school, and throughout life.
    I have never met a doctor who never makes mistakes.
    I have never met a surgeon who hasn’t caused complications from things done, or from things that “should have been done”, but weren’t.
    This is because:
    All humans make mistakes.
    All humans make mistakes every day.
    All doctors are human.
    All doctors make mistakes.
    All doctors make mistakes every day.
    Most of those mistakes result in no harm.
    Some of those mistakes cause mild to moderate harm.
    A tiny percentage of the mistakes made by physicians cause disability or premature death in patients.
    I believe it is likely that every single doctor who has ever practiced has harmed some of his or her patients, and has caused the premature death of some of his or her patients.
    Is this “wrong” or “bad”? I don’t think so. I think this is simply the human condition. So am I “defending” malpractice? No, I am just trying to get everyone to understand that every single doctor malpractices, and probably every single doctor’s malpractice kills patients. Doctors do an awful lot of good, but every single doctor does a small amount of harm. Some people and probably most lawyers think doctors who “commit” malpractice must be punished. Well, the lawyers aren’t doing a very good job, because every one of us physicians is guilty, and you haven’t “caught” all of us.
    Unfortunately, the only way to end malpractice is to end the practice of medicine. This is because it is impossible to train up even one perfect doctor, much less a nation or world full of them.
    Instead of having lawyers and their clients punish physicians who get caught in their mistakes (and as I say, every one of us physicians are truly guilty, you just haven’t caught every single one of us yet), why don’t those people strive instead to replace us bad doctors by becoming themselves “perfect” doctors?
    The answer is obvious. They can’t, and you can’t. NO one can. And so none of you try. It is just immensely easier to just complain bitterly about those of us who are actually ARE doctors, and try at every exposed opportunity to attempt to extort “justice” when you catch us.
    Here is a solution! How about having the lawyers pass legislation making it illegal for anyone to become a physician without assuring the rest of us that he or she will never make any mistakes, and swear upon pain of death or imprisonment to promise to accomplish that impossible task?
    Of course this will never happen. But if such a law were passed, every doctor who ever lived would immediately become a criminal for being incapable of obeying the law. In that circumstance, all doctors would have to immediately cease the practice of medicine. Paradoxically, if such a law were passed, the legal profession would have delivered an ultimate injustice to us all. America would be thrust back into a dark age where every disease and injury ran its natural course, maiming and killing literally millions of people. But we could all live happier having the satisfaction of knowing that no one would ever again have to suffer loss or death under the cruelty medical malpractice.
    Is this what we want? Of course not.
    Brothers and sisters, when will people realize these simple truths?
    It is time to begin to understand that if we want health care, we have to accept that it is delivered by mere mortals, all of whom are imperfect. Any non-physician who doesn’t believe this to be true, is welcome to take upon himself or herself the daunting task of becoming a physician and then trying to never make a mistake, never harm anyone, and never inadvertently kill a patient. Any person who tried to do this would learn (just like all of us physicians already know) that it simply can’t be done.
    Our current health care system does an immense amount of good. Brothers and sisters, please accept that our physicians’ inability to practice perfectly is not a reason to punish them for being unable to live up to humanly impossible standards. It is time for all of us to start applying the golden rule towards our physicians. It is time to have mercy on those people who are brave enough to try to help the rest of us by working every single day under the threat of having their entire livelihood taken away in a moment for any single perceived failure to perform to the impossible standards expected by non-physicians and their lawyers.
    Instead of complaining bitterly about how bad physicians are, consider being grateful for the incredibly wonderful things that they often can do. Consider acknowledging that medical malpractice will never end as long as doctors practice medicine. Malpractice to a large extent is a myth. Malpractice is merely the reality of true medical practice performed by ordinary men and women.
    Finally, please consider passing a constitutional amendment requiring all Americans to have mercy on their doctors who generally do a very good job in helping us all to live better, and to live longer.
    Blessings to you all.

  • Anonymous

    1) The sad fact is that good Doctors do make mistakes. Everyone does and good Doctors should not be punished for a simple mistake.
    2) Sadder yet, there are Doctors and Medical Staff that are incompetent and/or do not care, they also make mistakes and or are negligent. The truly negligent medical personnel should be sued and jailed.
    3) To make matters worse many Doctors are overworked and caring for too many patients at the same time.
    4) Saddest of all, Due to the large number of malpractice suits and the huge settlements, we as a nation are driving more and more doctors and would-be doctors to leave medicine. This only makes the problem worse.
    5) Worst of all, The high cost of medical care places quality health care out of reach for a large number of our citizens. The cost of medical malpractice insurance and these malpractice suits is a VERY large part of those medical costs. As a nation we will sue ourselves out of quality medical care in the near future.
    No, we do NOT need a National government run Health Care system. Most politicians are Lawyers and we certainly do NOT need a bunch of lawyers deciding how health care should be handled.
    Reduce the burden of malpractice suits on medicine by:
    a) fining lawyers for frivolous malpractice suits
    b) reduce the award levels in malpractice cases to reasonable levels (at least by 50% or more)
    c) Reduce the lawyers share of the award to 10-20% based on the number of hours they have worked on the case
    d) start aggressively prosecuting gross negligence and jailing the guilty, including administrative/management personnel that place medical proffesionals in impossible work conditions [long hours, short staffed (not enough people), inadequete staffing (inexperienced/undertrained), etc]
    Compensating the family of patients who suffered gross negligence is the right thing to do. However, we do not need to be making them and their lawyers millionares.
    Most Doctors and medical staff carry malpractice insurance so THEY are not the ones footing the bill. Everyone pays more for healthcare so they can pay for the high price of insurance, the insurance pays the price of the lawsuit and the lawyer who filed suit walks away with 50% or more. Who wins? The lawyers and the insurance companies. Who loses? The patients denied care, because they can not afford the high cost of health care and because there are fewer doctors.

  • just a patient

    Here in Illinois, the state legislature has put a cap on malpractice damages a few years ago. However, my doctor tells me that her malpractice insurance rates have not changed (ie not lowered). I think part of the solution is to legally rein in the greed of insurance companies.

  • Anonymous

    Reading this blog is somewhat terrifying….
    Here is a real life real time question? My 65 yr old husband has been diagnosed with an ascending aortic anuerism. The cardiologist says that it is of a size that could indicate surgery although she is not pressing for surgery. He is overweight, has a history of high blood pressure, and a family history of heart attack. He also has been hospitalized overnight 3 times lately for rapid heartbeat…I think that is unrelated to aorta problem.
    All not good. He is electing to NOT have the surgery….no matter what anyone says.
    MY QUESTION IS…..if he goes to the hospital in an emergency situation, how can I help make sure he gets the treatment he may need at that time? What do I need to do and say and take with me?

  • Anonymous

    My sister died from an Left anterior descending coronary artery dissection on November 16, 2006. She died four days after going to the ER with severe chest pain, cold sweats, nausea and upset stomach. I believe she also has tingling in her arm but not sure. She was sent home from the ER with a diagnosis of GERD!!!! Because she had a history of GERD, they did not even test further than a stress test and x-ray. Had they ordered a CT Scan and/or the artery test, that is more envasive. (Can’t think of what it’s called at the moment.) I ask does GERD cause cold sweats? Does it cause chest pain, well yes, but as I recall the pain is more intermittent, at least it was for me. Does GERD cause nausea and vomiting? Didn’t for me. And it certainly didn’t cause tingling in my arm/neck. I believe my sister could have had a chance at life had the doctors in that ER taken those chest pains and her other symptoms more seriously and done the tests needed to rule out any of the four deadly heart conditions that should have been ruled out. She may or may not have survived, but we will never know because she wasn’t given the chance. I can definitely sympathize with Ritter’s wife and family. They have every right to sue. And apparently others thought so too as they settled with her.

    I am contemplating a law suit as well. I haven’t had the strength to do anything yet, but it may just be the time t do so.

    Grieving MN sister

  • mz3thhall

    Dear Anonymous,
    To be pro-active in your husband’s future care, it would be extremely helpful to have a list of all of your husband’s medication allergies and drug intolerances, a 100% acurate medication list, and a comprehensive but concise summary of all of his medical problems. Put at the top of this list “known ascending thoracic aortic aneurysm”. Both of you need to remember to politely, but clearly state that “I am known to have an ascending aortic aneurysm, and I have been told to remind you that this thing can suddenly tear or rupture causing chest pain. Please carefully consider this possibility in my case.” Being forewarned is immensely helpful to physicians in an emergency setting.
    Blessings to you.

  • Anonymous

    I am the survivor of an ascending aortic aneurysm and dissection. On December 2, 2003, I woke up with chest pressure and radiating pain to my back. My doctor’s office was unable to fit me in but sent me to a local medical center. During the chest x-ray, I passed out and when i woke up, the ER doctor told me I had a heart murmur. I told him that it had never been diagnosed and he said it was a very loud murmur. I was sent by ambulance to a nearby hospital. I was a 42 year old woman with no significant medical history, low cholesterol and blood pressure. I spent six hours in the ER. I had the CT scan and then,not one, but two echocardiograms because the technician who they had caught on her way home couldn’t believe what she was seeing. By 6:30 I was again in an ambulance and was transferred to another hospital nearby who specialized in cardiac care. As I lay on the gurney, trying to comprehend that I was about to go into open heart surgery and receive a mechanical valve, my husband suggested I call our three children and say hello. I spoke to each of them briefly and told them I loved them. As I hung up the phone, I told my husband I was going to pass out. My aorta dissected and I was rushed to surgery. Five hours later, I had survived the surgery. The surgeon shared with my husband that I had flatlined on the operating table and that it had taken significant time to stabilize me.
    I do not have a lot of memory from the first few days of this event. But I will say that the doctors, nurses and staff of the ERs did everything they could to help. And the further I move away from that date in December, the more I realize that my survival was not just because of the amazing surgeon that was on call that night and operated on me but because of the dozens of people who did their best to help me. I have been told by my sister, who has been a nurse for almost 30 years, how low the survival rate is for an aortic dissection. I was right there, literally next to a surgeon, when mine occured. And I was SO fortunate to have made it through surgery. So despite how wondrous medicine is and how advanced it gets, I still think you need a little luck…thats the only way that I can explain why I am still here. And I agree with Dr. Rogers – picking up on it does depend on how often the doctors consider it. I have been told over and over that I did not have indicators for it – nothing that would have made them initially suspect that. For me, that is the scariest part. I can’t imagine how the ER docs do it – it must have been like trying to find a needle in a haystack.
    I just felt like I had to share – I don’t know the true numbers of people that survive and as heart disease is the number 1 killer of women now, I do think we need a lot more education and awareness.

  • Anonymous

    I have been in and out hospitals for the past 20 straight years. 18 with my Son and the last 2 with my Wife and I. I was 46 and had an Abdominal Aortic Anyuerism 8cm at time of Surgery. I was having lower back pain and had seen a couple of doctors, neither of which ordered a C/T scan. The pain management specialist sent me to have a MRI of my lower back. Half way through the MRI I was asked to come into the imaging booth where they showed me the AAA. Yep I was stunned, but not afraid. I was confident that since this was caught before it ruptured I would be fine. I had 18 inchs of Aorta replaced with Dacron tubing, Thanks to a Korean Christian Surgeon, Dr. Choi at Baltimore Washington Medical Center I am in excellant health now. I have met some very arrogant Docs and some very eloquent Docs, just people all the same, some with more talent some with not so much talent, but still like all of us flawed and fragile creatures of God. So the next time you want to blame the Docs for a bad diagnosis, before you do, go home turn on CNBC financial news and watch the ticker as Human Blood gets traded on the NYSE. I am convinced the people who buy and sell blood are the ones to blame, C/T and MRI Scans should be the NORM! Scans would be the norm if the American People had Political clout like the Health Insurance lobbiest had. The Scum who trade your blood futures try to please the shareholders before you. The God gifted Doctors and Nurses who sometimes work around the clock catch all the crap, not all of them got into healing for the money. They are a patsy for the blood traders. It wasn’t the Doctors I blamed for not diagnosing my AAA, it was the system.

  • Anonymous

    It is simple math. Aortic dissections are uncommon, chest pain is common. If we scan every patient that comes through the ER. The miss rate of aortic dissection will be extremely low.

    Your monthly insurance premium will be extremely high(er).

    Not to mention that if you have multiple such episodes over your lifetime, you will receive a potentially cancer inducing dose of radiation.

    Society must decide which it will be. Suing the doctor makes some lawyers very happy. It, unfortunately, does not solve the problem.

    MD

  • Adella

    I am not American and I am APPALLED by Americans suing about every thing.
    Doctors don’t have super powers! They miss things but mostly, they do a damn good job.

    Keep suing or complain about the price of health care. Choose one!

  • Anonymous

    Reading a CT scan (CAT scan) is not like reading a book. There can be very subtle and ambiguous findings that even experts will not agree on. Similarly aortic dissection is difficult to diagnose. It WILL be missed. As many have pointed out, ordering CT scans on everyone with chest pain is NOT an answer. There will always be differences in the quality of health care. Not everyone can get the best surgeon for every operation. Just remember, law suits like this take millions of dollars OUT of the health care system. Money that could be spent improving health care. Doctors work incredibly hard. Have you ever worked 40 hours in a row? Without stopping? How about repeatedly, as in every 3rd day? Have you worked 12 hours on your feet without even a bathroom or lunch break? I have, and I can tell you it is not fun. Do you think a Doctor wants to miss a diagnosis, or doesn’t feel bad when a patient dies? Have you ever had the responsbility for someone’s death on your hands?

    The problem is you have to distinguish between a mistake and negligence. Mistakes will happen. The way to improve them is analyze why mistakes are made and improve the system. Blaming individual doctors is not going to work. It’s just going to drive the best and brightest out of the business. Doctors that are negligent, on the other hand, should be crucified. I have no problem with that. There needs to be a systematic way to dinstinguish the two. Of course there will always be a gray area. But that should be focused on. As for the case of missed dissections, often symptoms that support the diagnosis are “cherry-picked” from ALL the symptoms the patient had, and present a very misleading view of the case. Diagnosing a patient, or reading a CT scan in retrospect is ENTIRELY different from doing it up front. People passing judgement on these doctors may be right, but until you’ve been there, you have no idea.

  • wakwak

    There is no comeback against the wise words of “Mortal Doc”.

    He has said it all.

    The bitter whining and baying for physicians’ blood will continue, but that is the ugly side of humanity.

    Australian Anaesthetist.

  • Anonymous

    THis comment is in refernce to grieving MN sister. I am truly sorry for your loss. But if you think that a regular aortic dissection is hard to pick up (which it is), a left anterior descending coraonary artery dissection would be virtually impossible!! THe majority of heart attacks that present with aortic dissection are due to dissection of the right coronary artery. it is possible your sister had an anomoly where the left anterior descending artery would be affected from an aortic aneurysm. i don’t know the specfics of your sister. however, an xray, cat scan of the chest, or ultrasound will not show an isolated LAD dissection. IT is very very rare. and i do see patients who have bad chest pain who just have GERD. hindisight is always 20/20, but only GOD knows it all. not doctors

  • Joshua

    Regarding various comments on the “cost” of a CT scan. In one study done on head CTs performed in an ED, the average cost billed to insurance was $300. (the study concluded that even at $300 it was not indicated for the symptom of headache). But don’t let your doctor bluff you on not doing a CT because it’s too expensive. I don’t know how much more a chest CT costs but it’s NOT the $3000 dollars someone suggested. Sure it might say some inflated number on the bill but your insurance co. is paying a few hundred dollars.

    And even if it was $1000 extra, if you the consumer is so smart about your diagnosis, then ask for a CT and offer to pay for it. What, you’d pay $1000 a year for cell phone use but not for a CT that could save your life??? I think there should be a separate line in the ED where you can swipe your credit card and order whatever tests you think you need at the rates billed to the insurance co. A lab tech could come in and draw the blood and another tech does the CT or whatever (no, your doctor doesn’t usually do those test like they do on TV). then you could sit down with your harried ED MD and present the results. Pay up or shut up america.

  • Anonymous

    Well I’ve read all of the comments and have the following opinion. There are difficult diagnosises that a competent doctor will miss, there are difficult diagnosises that will be missed due to incomptetnet doctors, and there are missed diagnosises by doctors who refuse to listen to the patient and/or their family because they couldn’t possibly know more than him/her.

    My family physician missed the fact that I had endocarditis for 4 months. The first time I went to him I filled out the medical history sheet that I assume goes in the patient’s chart. I wrote on mine that I was born with a VSD (large) that had not been repaired because I had been generally asymptomatic. At age 17 they detected that the shrinking (but not closed) VSD was causing aortic valve prolapse and aortic insufficiency. Fast forward to 2003 and I get a nasty case of bronchitis I can’t shake. After a few rounds of antibiotics, then steroids accompanied by M-Clear cough syrup we finally beat the bronchitis. But then I presented over the next few months with a low grade fever, night sweats that became increasingly worse, prostititis, swollen hands and feet, painful joints, and eventually a dull pain between my shoulder blades. I was going downhill fast. About 3-4 weeks before I was diagnosed with IE I told him that I was worried that I might have it. He dismissed me and said you don’t even have a murmur. I guess a (now) small VSD and moderate aortic insufficiency can not be detected by the “average” doctor when he/she listens to your heart. I kept going downhill and I finally insisted that he run a blood culture on me. The culture was performed on a Friday afternoon and he called me on Sunday morning to let me know that it had already come back positive and was going to call me in some Cipro 750mg. On Monday I was so ill I called him back and insisted that I get an echo. The echo was perfomed Tuesday afternoon and I was admitted to the hospital Tuesday afternoon with infectious endocarditis. After 7 weeks of an IV regimine of Rocephin 2gm daily I had a cardiology consult (which my doctor didn’t think I needed) where I found out that I needed to have by aortic valve replaced and my VSD repaired. BTW I had a Ross Procedure at Duke.

    OK doctors…was this a case of a difficult diagnosis that happened to be missed by my doctor or a case of malpractice? Remember that I filled out the patient history sheet stating that I had AI and a VSD. I reminded him of that and he said I didn’t have a murmur. I told him that after researching the symptoms of endocarditis I had all of the classic symptoms. I had to prod him to do a blood culture (even though my white count was higher every time it was taken) and an echo.

    Guess what…I didn’t sue him. Not because I didn’t think he was negligent, but because I thought he was trying to help me the best he could. IMO his 2 main mistakes were not reviewing my past medical history (or not connecting that history with being at a higher risk of contracting IE) and NOT LISTENING TO THE PATIENT. When a complete stranger comes into the ER who do you think knows their body better…you who have known the patient for 2 minutes or the patient and/or family member? I honestly think that if doctors would actually listen to their patients better it might make it easier to make a correct diagnosis. I realize not all patients/family would be intelligent advocates for themselves, but that’s part of being a good doctor…having a sense for which patients can help you diagnosis their problem and which ones can’t.

    Sorry for the thread jack on dissections. BTW…IMO I think dissections are much more common than most people think, but unless an autopsy is performed it is often considered a heart attack if the patient dies before being diagnosed.

  • Anonymous

    I have enjoyed reading everyone’s comments. I think that as technology continues to advance we will have faster and safer imaging modalities (machines) which will in fact enable us to get detailed images of everyone who presents with chest pain. For instance today we have a lot more success in accurately diagnosing the cause of abdominal and pelvic pain in ER (compared to years ago) mainly thanks to the liberal use of ultrasound and CT scan.

  • mortaldoc

    You are right in thinking that your doctor should have considered endocarditis early on. Patients with persistent fever of “unknown origin” whether they have a murmur or not should have blood cultures done because subacute bacterial endocarditis is always in the list of possible causes. And it is lethal if not detected and correctly treated. Also, I have to say that oral Cipro (or any antibiotic) is almost never the correct drug for any infection serious enough to cause positive bacterial blood cultures. It is certainly not correct treatment for endocarditis.
    Yes, physicians should extra vigilant to consider endocarditis in a patient like you who has a VSD and/or aortic insufficiency with or without a murmur.
    I am sorry that you had your experience. Unfortunately I don’t know how to make all physicians (even myself) perform to the highest standards possible since they (we) are all humans with human failings. I hope and pray that you do well from this point forward.

  • mortaldoc

    I have to make a correction. The phrase “or any anbitioc” should have said “or any ORAL antibiotic”. Intravenous antibiotics are absolutely the primary treatment for bacterial endocarditis.
    The error is regretted.

  • Anonymous

    mortaldoc,

    Thank you for your comments and your well wishes. Today (3/17) is the 4 year anniversary of my Ross Procedure. I had my annual follow up about 2 months ago and both valves are functioning perfectly and my slightly dilated aortic root (3.7cm) has not changed in 2 years. I realize that dissections are difficult to diagnose because the symptoms can mimic so many other problems. That’s why I think that when someone enters the ER with chest pain a simple list of questions may shed some light on whether or not this person may be at risk of aortic dissection. Since many cases of aortic dissecton accompany patients with bicuspid aortic valves, Marfans, or other connective tissue disease…asking them questions about their family history may be the “needle in the haystack” that doctors are looking for. If they have a family history of family members dying of “heart attacks” at a relatively young age that would be a major red flag. Also listening to the patient when they explain their symptoms may help doctors differentiate possible causes for those symptoms. I think part of the problem is that since ER docs don’t experience many patients arriving with aortic dissections it’s too easy to lump their symptoms with other, more common health issues that they see much more frequently. But one thing I’ve noticed in most of the testimonials here from dissection patients or their family members is that with treatment the symptoms did not subside…another red flag. That’s why I learned early on that I (or my family) had to be my own “patient advocate” and not feel too intimidated to question a doctor’s diagnosis and/or treatment. Some doctors don’t appreciate this, but when I’m sick and feel like there may something seriously wrong the last thing I’m worried about is bruising someone’s ego. I’d rather be wrong and apologize to the doctor later than be right but kept my mouth shut with catastrophic results.

    I have a lot of respect for physicians and their dedication to helping people, but like other doctors have said here they are only human and will occasionally miss a diagnosis. That is where a well informed patient may make a difference in helping the doctor narrow down the possible causes for the symptoms they present when they arrive at the ER (or doctor’s office). This is assuming the doctor is willing to listen to the patient and take them seriously.

  • Nitedoc

    This may not be read by anyone since it has been a long time since Dr. Rogers posted his comments. I “Googled” Ritter’s cause of death after seing his wife on some Hollywood news show last night. She indicated that a “heart” painted on a mural of Mr. Ritter was directly over the spot where his aorta ruptured. Only problem… the heart graphic is on the high right side. a little education still needs to be done on the plantiffs side.

    As per all these other posts…

    Many of the case discussions involve disappointed and grieving family members of those that had a missed diagnosis. This is, of course, sad for the individual but is not reflective of the ED community as a whole. There is simply no impetus to write in and share a case in which rapid diagnosis was made and the patient did well. This is bias sampling which is common in anedotal reporting. As an emergency physician in Michigan, I can assure the public that AAA and Thoracic Dissection is part of every single lecture regarding heart disease and critical care ED medicine. There will always be missed diagnosis regarding virtually every chief complaint. It does not mean the physician community as a whole is uneducated or complacent. I had a man die in the ED who had this horrible disease and yet presented with resolved nausea/vomiting and had NO chest pain, NO abdominal pain and had a normal routine work-up including CXR. It can be tough to pick up and yes, doctors, it can be obvious and sometimes ignored. I don’t think Mrs. Ritter’s 67 million lawsuit is the kind of education that the medical industry embraces. That is simple hyperbole from a “Hollywood” mentality. That said, a loss is a loss, and we all deal with it in different ways.

    Grand Rapids Emergency Physician. 20 shifts a month, 20 years and still going.

    A side comment… Working one ED shift a month does not make one an “Emergency Physician” it makes one a physician that works in an emergency room… and the repeated use of the “F” word does not engender the respect we physicians seek to earn from our patient population.

  • Anonymous

    In Sept.2000, my friend Kim Hawkins died suddenly of Aortic dissection. Thats what her autopsy report said. She was the manager of Kritinas Natural Ranch Market in Fresno, Ca. Is there any way a person could be ‘murdered’and some kind of drug or something could cause aortic dissection? My ex-husband Jim Belcher, who owns the health food store, collected a large death benefit he owned on Kims life. I excaped dyeing in an “accident”, that I knew my now ex had set me up for, by a strange comment he made afterwards. Jim still owns my life insurance policy, due to him having Company owned life insurance on all his employees. There are about four deaths that I know about. No proof, but I know…..

  • Anonymous

    My brother inlaw passed away from a Triple A this past weekend, he was seeing his primary care doctoer when he experianced sudden lower back pain, numbness of the legs and sever vomiting, he was sent to the ER where he spent 8 hours under a doctors care, the Emergency room doctor gave him medication to help controll the vomiting, took a urine sample and determined that because the man was mentally challanged and over weight he sufford from sciatic
    nerve problems causeing the leg numbness, after nearly 8 hours in the ER he was discharged with a script for pain medication, placed in a taxi and sent home, living only 10 minutes from the local ER this is where the story takes a sad turn, he never made the ride home, he died somewhere between the ER and his apartment building, the poor taxi driver turned to ask him which apartment was his only to find a dead passenger in the back seat… AAA was the final diagnosis by the M.E, now the case has been turned over to the NEW YORK States attorneys office becausee he was mentally challanged on Medicaid and spent 8 hours in the ER only to die on his way home…

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