I was perusing my blog feed this morning and came across a CNN article discussing the wrongful-death lawsuit against doctors who treated the actor John Ritter. Ritter was treated for a heart attack, when in fact he was actually suffering from a “torn aorta” as the article puts it, which in more technical terms is an “aortic dissection.”
It’s tragic that he (or anyone for that matter) has to die at such a relatively young age – 54 is much to early to go. But for me the significance of the case is to serve as a great reminder of how non-scientific medicine can be. Don’t get me wrong – there’s a lot of science to medicine, and a lot of treatments are prescribed because of solid evidence and many years of research comparing different treatments with outcomes. You’d think by now we’d be experts at treating someone who comes to the emergency room complaining of “chest pain”, until you realize how many different problems can present themselves under that single descriptive term. We’re taught in medicine to come up with a list of possible diseases each time a patient complains of a certain ailment – we call this the “differential diagnosis” and it includes both what we think is likely to have occurred as well as a list of long-shots. For instance, if someone came to the hospital with “chest pain” a doctor would consider serious problems such as heart attack, pulmonary embolism (blood clot to the lung), aortic dissection (torn aorta), pneumothorax (collapsed lung), and cardiac tamponade (blood around the heart that limits its pumping ability)…but would also consider benign problems such as indigestion, esophageal spasm, etc. They then go through their list and try to target their questions to rule in/out the various conditions, focusing on the more serious ones first since those pose the most immediate threat. In the case of John Ritter, his family history of heart problems may have come into play. Medications, alcohol/tobacco use, or previous medical ailments might also influence which diagnosis you lean towards.
I should add at this point that I’m not a doctor, let alone a cardiologist – I’m a medical student with a very introductory understanding of how this process works. Most emergency room doctors would have probably considered the various problems listed above, taken a detailed history of the patient, and then decide which course to pursue. If they suspected a heart problem, they would probably obtain a chest x-ray as well as an EKG to look for electrical abnormalities that might indicate a heart attack (and call the cardiologist to come down and examine the patient). But this is where it starts to get tricky – an EKG is a great tool, but will not always show electrical changes even if someone has had a heart attack or is on the verge of a heart attack. Thus if the patient’s history strongly suggests heart attack but is not confirmed by an EKG, the doctor might still treat as if it were so. I have no idea what happened in the case of John Ritter, but perhaps that is one possibility of what took place. The classic presentation of aortic dissection is sudden onset chest pain that migrates…if Ritter’s pain wasn’t radiating (or if the doctor didn’t ask whether it was radiating) that diagnosis might be missed – that doctor would not have ordered a CT scan to look for tearing of the aortic wall, and might go on to treat as if the patient had something else.
Even if it is caught, aortic dissection is a terrible diagnosis with a very high death rate – surgery is required to immediately fix the tear before it occludes blood flow to vital organs and causes permanent damage/death.
In summary, I’m not writing this post to make excuses for the doctors involved in the case – I have no idea as to the specifics involved and what was or wasn’t considered. I’m merely trying to provide insight into how this whole medical process works, since most people outside the system are entirely clueless. Medicine is a wonderful tool with the potential to have huge impacts on our health and quality of life…but it is a mix of science and art, with the two frequently so intertwined that it may be difficult to distinguish where one stops and the next begins. Fancy tests only tell you so much, and are generally meaningless without a thorough history of the patient (I wonder how much money we could save by simply providing more time for talking with the patient, which may then allow us to avoid having to use the fancy high-tech toys at our disposal). Regardless of whether John Ritter’s death was the result of a medical mistake or an inevitable outcome, it’s tragic that he had to die at a young age. Hopefully medicine will evolve to provide more accurate distinctions between the various types of “chest pain” so that such tragedies may be avoided in the future.