Dr Mike Knapton: 'If an aneurysm goes undetected, the patient can die very quickly'
My toughest case
Tuesday 05 July 2011
I'm a general practitioner and on this day I was called out to the home of a 75-year-old woman who was complaining of abdominal pains. It was the run-up to Christmas and the house call was a non-urgent visit. She had taken to her bed and her daughter had come round to make sure she was OK.
However, she had had pains for about three or four days and finally called me to come and have a look. She had a normal pulse and blood pressure, no obvious real signs of pains, but she commented on how she suffered a particularly severe and intermittent pain that was felt in her back. These symptoms can indicate the possibility of a ruptured aortic aneurysm, but it is rare to come across in general practice.
On the one hand, with a ruptured aortic aneurysm, if it goes untreated and undetected, the patient can die very quickly. However, the symptoms and signs were relatively subtle, and I did not want to call for an ambulance and send her to the local A&E unnecessarily, particularly when I am urged not to make expensive hospital referrals by the PCT. I decided to pursue it, as the referral would just involve going to hospital for an ultrasound and if they found nothing, she could go home and enjoy Christmas. If they found something, it could save her life.
However, the big problem was that I could find no-one who wanted to take her. I rang around local hospital departments, general surgery, vascular surgery and the emergency assessment unit and their central retort was that "it's not our problem". I was challenged: "what makes you, Dr Knapton, think it is an aortic aneurysm?", and I would reply, increasingly frustrated, "Well I've personally assessed them and I'm their consulting doctor!"
So, it took 90 minutes on the telephone for someone to finally accept her, and I arranged for an ambulance to transport her to hospital. She went in to hospital, had an ultrasound – and my gut instinct was proven correct, and they took her to operating theatre that evening. She recovered in time to spend time with her family at Christmas.
I guess the main lesson to learn here is trust your gut instinct.
The NHS Abdominal Aortic Aneurysm (AAA) screening programme aims to identify AAA and reduce deaths from ruptured AAA. Once fully implemented, the programme will invite all men for screening during the year that they turn 65. Men who have an aneurysm detected will be offered treatment or monitoring depending on the size of the aneurysm.
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