When diagnoses come in threes

We tend to like threes.

Hendriasis, in Greek — one through three, is a figure of speech used for emphasis in which three words are used to express one idea. For example: Veni vidi, vici. Location, location, location. Or one of the anthems of my youth — sex drugs and rock n’ roll. Monty Hall had three doors on “Let’s Make a Deal.” Even Uncle Junior, the patriarch in the “Sopranos,” noted that (heavy New York Italian accent here), “They come in threes.”

The penchant for threes shoots through the fabric of our existence. Whether due to the wiring of our brains, mysticism or the Holy Trinity, the nearly pathological penchant that “things” comes in threes can lead to almost paralyzing fear while waiting for that third event to occur.

Nowhere is this truer than in the emergency room where superstition is closely observed. For example, never say the word “quiet.” If you mention a patient’s name, they will show up. And walking into an empty trauma bay invites shootings and stabbings.

I was working a busy shift on a Sunday afternoon and walked into room 6 to see a gentleman that complained of feeling dizzy. Sitting in a chair, fully dressed and chatting comfortably with his wife, this 62-year-old minister related that while preaching, he had the feeling that he had to go to the bathroom. He became sweaty and lightheaded. He sat down and after 15 minutes the symptoms resolved. His wife had cajoled him into coming to the ED to be evaluated. His past medical history included hypertension and chronic back pain. On exam, he was an obese man and was still slightly damp from sweating. The remainder of his physical exam was normal. But I was suspicious. A workup, including chest X-ray, labs, and EKG, was all normal. While sitting in the bed, he requested, but did not receive, pain medication as his chronic back pain was acting up. Soon thereafter, he became sweaty and lightheaded. His blood pressure had dropped precipitously. After some IV fluid, he improved, but his back pain had become worse. Ultrasound revealed a 10 cm abdominal aortic aneurysm or “triple A” that CT confirmed had ruptured posteriorly. He was rushed to the operating room.

The aorta is the large vessel that exits the heart and supplies oxygenated blood to the entire body. A ruptured triple A is a catastrophic event with death occurring in over 50 percent of those that survive to the operating room. Although ED physicians are aware and constantly thinking of this diagnosis, in patients presenting with symptoms that may indicate a ruptured triple A, we may only see a few in our lifetime.

A week later, a 72-year-old gentleman presented with severe back and leg pain. He had a history of hypertension and noted that over the preceding two days he had been experiencing some nausea and vomiting. That morning he had thrown up violently and immediately noted severe back and left leg pain. His wife brought him to the ED. On examination, he was clearly in severe pain. His blood pressure was elevated as was his pulse. He was tender in the left flank, and I was unable to palpate any pulses in the left lower extremity. Ultrasound of the abdomen revealed a 7 cm triple A with retroperitoneal rupture and dissection into the left iliac artery. He too was sent directly to the operating room.

That second patient presented a week ago. I have worked a few shifts since then and cannot stop looking around every corner for the third patient with a ruptured AAA. He or she is out there, just waiting for my next shift. I know it. Will it present classically so that the diagnosis is straightforward or will the presentation be sublime?

They come in threes. They always do.

Robert J. Wagner is an emergency physician.

Image credit: Shutterstock.com

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