A few weeks ago at the VA, I was involved in the incidental diagnosis of an aortic dissection. It was all really chaotic and confirmed my dislike for chaos in the face of a critical medical situation. Mr. C is a 79 year-old man who I had followed briefly in the ICU after he had surgery for a small bowel obstruction (also found incidentally) and was on a mechanical ventilator. I remember giving him sponges for him to moisten his mouth with and he was very appreciative. He was then transferred to the floor and I was no longer following him, but the cardiology service was because he had a bunch of heart problems. I was shadowing the cardiologist who was just going into Mr. C's room to do a bedside ultrasound to look for something cardiac-related (I honestly can't remember what we were looking for, but it wasn't serious). Mr. C was screaming in pain that had started pretty acutely. We didn't think much of it, just a very old man with probable arthritis in his back sitting uncomfortably in the chair. Then the cardiologist saw what looked like a false lumen in the patient's left carotid artery on ultrasound. That coupled with back pain = aortic dissection.

This mad just had surgery. He had heart disease, a recent heart attack, blood in his urine, and bacteria in his blood. He was not a candidate for aortic surgery. And he didn't want it either.

We all knew this meant the end for Mr. C. The cardiologist even used the word "goner" with nervous laughter. Not out of cruelty, but just matter of fact. This made me very sad. David's maternal grandmother also died from an aortic dissection. I felt the heaviness of it all.