Title Borrowed from the OB/GYN Forum: What's your most interesting/scary case?

I had an elderly patient who came in for chest pain. Got to ER about 5 pm, came up late on night shift from the ER, still having a lot of pain.

As I was getting the patient settled, I had trouble getting a blood pressure. I got a very Bad Feeling about this patient. Patient was a/o X3, cracking jokes, and when asked, told me there was continuing shoulder pain, but what flipped my danger signal was the quality of the pain.

Patient said, "Hurts back here," and indicated the left scapula, "and it's so intense, it feels like it's ripping."

Thunk. My heart dropped to my feet and I know my face went white and a thought popped into my head--"My God, this patient is having an aortic dissection." My second thought was, "FYI, Nurse Drama Queen, if it was a dissection, the patient wouldn't have survived long enough to get to the ER."

The family wanted to leave, but I made a couple of them stay, ostensibly so that they could give me admission info. But it was really because I was terrified that this patient was going to suddenly Code on us. I called the doc pronto. I asked for medication, and in describing the symptoms, actually mentioned that Patient's pain was beyond the norm for an MI, and in fact, signalled something else--like maybe an aortic dissection. So the doc prescribed a strong pain reliever.

So I medicated the patient and had the family present to see that the medication had taken effect and then we did the paperwork.

The gut feeling persisted so badly that this was the patient I asked about first thing when I worked next.

I found out that the patient was indeed dissecting--and the location involved more than the aorta--it was everywhere. There was no medical or surgical intervention that could've helped the patient.

It still amazes me that somewhere in my memory, the two huge red flags--the inability to get a blood pressure easily and the shoulder pain--must've sparked my gut response. I never dreamed I would even see a patient with this Dx since I didn't work ER.